L5 Nerve Root Compression Research Articles

A CASE STUDY ON THE ROLE OF TIKTA KSHEERA BASTI IN THE MANAGEMENT OF KATIGATA VATA WITH SPECIAL REFERENCE TO LUMBAR SPONDYLOSIS

Katigata Vata or Lumbar spondylosis produces low back pain radiating towards the gluteal region of the leg and further towards the great toe. Symptoms include pain, stiffness, tingling numbness, difficulty walking, etc. No unique entity can be connected to Lumbar Spondylosis in Ayurveda. Under Vataja Nanatmaka vikara, it is classified as Katigraha (Stiffness in the lower back). Hereby presenting a case of 62 years old male who visited our institute with the presenting complaints of Katishool (low back ache), Sakashta Chankraman (Difficulty walking), Pain radiating towards the back, and an MRI Lumbar Spine which reported Osteoporosis at the Posterocentral disc protrusion at L2-L3, L4-L5 with L3 and L5 nerve root compression. He decided to undergo Ayurvedic panchakarma therapy along with Shaman Aushadhi. The treatment schedule of 21 days was planned to include therapy of Panchtikta Ksheera Basti along with shaman Aushadhi. Tikta Ksheera Basti tried to reduce the signs and symptoms of patients with Lumbar spondylosis after taking all these aspects into account. The following aspects of low back pain, tingling in the lower back and lower limbs, stiffness in the lower back and lower limbs, joint movements in the lower back and lower limbs, and the Straight Leg Rising Test (SLRT) were evaluated. Before and after administering Basti Karma, the data were gathered. The signs and symptoms of Lumbar Spondylosis were dramatically reduced throughout this 21-day basti, which showed significant efficacy.

Full Endoscopic Decompression for a Misdiagnosed Far-Out Syndrome (L5/S1 Extraforaminal Stenosis) in an Elderly Patient with L5 Radiculopathy: Case Report

We present a case of a L5/S1 extraforaminal stenosis (EFS), also known as far-out syndrome, in which ineffective multiple previous fusion surgeries were performed because of misdiagnosis. An 83-year-old man, complaining of back and left sided leg pain along the L5 dermatome for 5 years visited our institute claiming persistent pain even after 2 fusion surgeries at another hospital. A new magnetic resonance image (MRI) scan with a half coronal T1-weighted sequence revealed left L5/S1 EFS and resultant L5 nerve root compression. Because of the patient’s old age, history of angina and anti-platelet medications, a minimally invasive full-endoscopic decompression was performed. Afterwards the patient experienced immediate relief of the radicular pain, satisfied with the surgery. Diagnosis of L5/S1 EFS can be challenging especially when only routine sagittal/axial MRI scans are provided. Half coronal plane T1-weighted image MRI can be extremely helpful in diagnosis of this distinct pathology. Through this case report, we would like to emphasize the significance of half coronal MRI in diagnosis of L5/S1 EFS and also show a representative successful full-endoscopic decompression for the disease.

Fast Independent Component Analysis Algorithm-Based Diagnosis of L5 Nerve Root Compression and Changes of Brain Functional Areas Using 3D Functional Magnetic Resonance Imaging.

In this paper, the application of 3-dimensional (3D) functional magnetic resonance imaging (FMRI) in the diagnosis of the 5th lumbar (L5) nerve root compression and brain functional areas in patients with lumbar disc herniation (LDH) was analyzed. The traditional fast independent component analysis (Fast ICA) algorithm was optimized based on the modified whitening matrix to establish a new type of Modified-Fast ICA (M-Fast ICA) algorithm that was compared with the introduced traditional Fast ICA and ICA. M-Fast ICA was applied to the 3D FMRI diffusion tensor imaging (DTI) evaluation of 65 patients with L5 nerve root pain due to LDH (group A) and 50 healthy volunteers (group B). The values of fractional anisotropy (FA) and apparent diffusion coefficient (ADC) in the lumbar nerve roots (L3, L4, L5, and the 1st sacral vertebra (S1)) were recorded among subjects from the two groups. Besides, the score of edema degree in the lumbar nerve roots (L5 and S1) and activity of brain functional areas were also recorded among all subjects of the two groups. The results showed that the mean square error of M-Fast ICA was smaller than that of traditional Fast ICA and ICA, while its signal-to-noise ratio (SNR) was greater than that of Fast ICA and ICA (P < 0.05). The FA of L5 and S1 nerve roots in patients of group A was sharply lower than the values of group B, while the ADC of patients in group A was greater than that of the control group (P < 0.05). Besides, the score of edema in L5 and S1 nerve roots of patients in group A increased in contrast to group B (P < 0.05). The brain areas were activated after surgery including bilateral temporal lobe, left thalamus, splenium of corpus callosum, and right internal capsule. In conclusion, the 3D image denoising performance of M-Fast ICA optimized and constructed in this study was superior to that of the traditional Fast ICA and ICA. The FA of patients with L5 nerve root pain due to LDH decreased steeply, while the ADC increased dramatically. L5 nerve root pain caused by LDH resulted in changes in brain functional areas of the patients to inhibit the resting state default network activity, and the corresponding brain functional areas could be activated through treatment.

High grade isthmic spondylolisthesis – A case series illustrating three different operative instrumented fusion techniques

Adult isthmic spondylolisthesis most commonly occurs at the L5-S1 level. In adults a high-grade slip degree is rare comprising less than 1% of cases. Progressive axial lumbar backache characterizes the early stage of the disease which over time commonly complicates with the development of a super-imposed L5 radiculopathy. These are difficult cases to manage and the attending spinal surgeon must have an understanding of several different surgical options. These options include conservative treatment in those who are mildly symptomatic, decompression alone with its inherent tendency to facilitate further slip, decompression and fusion without instrumentation, decompression and fusion with instrumentation, and if so the extent of the construct both cranially and caudally. Another important consideration is whether, or not, reduction is necessary or whether fusion in situ will suffice. Regarding the surgical approach some surgeons regard an anterior approach, to perform an anterior release, as necessary if reduction is to be achieved. Others consider nerve root decompression and posterior spinal fusion in situ as the technique of choice. Others advocate a combined anterior and posterior surgical approach.We report a case series of three adult female patients with high grade isthmic spondylolisthesis complicated by L5 nerve root compression. Each patient was successfully managed with a different instrumented fusion technique. Our case series serves to highlight several of the specific surgical nuances pertaining to the management of high-grade isthmic spondylolisthesis and as such is valuable to the attending spinal surgeon who may infrequently encounter patient with the high-grade form of this disease.

Extraforaminal entrapment of the fifth lumbar spinal nerve by nearthrosis in patients with lumbosacral transitional vertebrae.

Lumbosacral transitional vertebrae (LSTV) often have nearthrosis between the L5 transverse processes and the sacral ala; this causes the formation of new bone and synovial-like tissue, which can entrap L5 nerve root. The present study aimed to examine the role of nearthrosis in L5 nerve root compression in patients with LSTV. From 2008 to 2018, 65 patients were surgically treated for severe leg pain/numbness caused by L5 extraforaminal stenosis. The patients were assessed regarding the presence of LSTV, radiographic features of nearthrosis, operative/radiological findings, and clinical outcomes. CT/MRI were used to classify the patients into three groups: group A had L5 nerve root compression that was not related to nearthrosis, group B had L5 nerve root impingement due to nearthrosis with new bone formation, and group C had L5 nerve root impingement due to nearthrosis with synovial-like tissue. The relationships between the type of LSTV (based on the Castellvi's classification) and these three groups were investigated. Although 26 of 65 patients had LSTV (40%), four were excluded because of less than 1-year follow-up. The 22 patients with LSTV were classified as type IA (n = 2), IIA (n = 13), and IIB (n = 7). In accordance with the radiological findings, there were eight patients in group A, six in group B, and eight in group C; the LSTV morphology did not significantly differ between groups. L5 nerve root was compressed by nearthrosis in 64% of symptomatic patients with LSTV; this region should be carefully assessed in all symptomatic patients with LSTV.

Where do patients with MRI-confirmed single-level radiculopathy experience pain, and what is the clinical interpretability of these pain patterns? A cross-sectional diagnostic accuracy study

BackgroundClinicians nominate the distribution of leg pain as being important in diagnosing nerve root involvement. This study aimed to identify: (i) common unisegmental radicular pain patterns and whether they were dermatomal, and (ii) whether these radicular pain patterns assisted clinician discrimination of the nerve root level involved.MethodsA cross-sectional diagnostic accuracy study of adult patients with radicular leg pain at a hospital in Denmark. All patients had positive neurological signs (average 2.8 signs - hypoalgesia, diminished reflexes, muscle weakness, positive Straight Leg Raise test).Part 1 (pain patterns) was a secondary analysis of baseline pain pattern data collected during a clinical trial. The pain charts of 93 patients with an MRI and clinically confirmed single-level disc herniation with nerve root compression were digitised and layered to form a composite picture of the radicular patterns for the L5 and S1 nerve roots, which were then compared to published dermatomes.In Part 2 (clinical utility) we prospectively measured the discriminative ability of the identified pain patterns. The accuracy was calculated of three groups of six clinicians at classifying the nerve root affected in a randomized sequence of 53 patients, when not shown, briefly shown or continuously shown the composite pain patterns. In each group were two chiropractors, two medical doctors and two physiotherapists.ResultsThere was a wide overlap in pain patterns from compromised L5 and S1 nerve roots but some distinguishing features. These pain patterns had approximately 50 to 80% overlap with published dermatomes. Clinicians were unable to determine with any accuracy above chance whether an individual pain drawing was from a person with a compromised L5 or S1 nerve root, and use of the composite pain drawings did not improve that accuracy.ConclusionsWhile pain distribution may be an indication of radiculopathy, pain patterns from L5 or S1 nerve root compression only approximated those of sensory dermatomes, and level-specific knowledge about radicular pain patterns did not assist clinicians’ diagnostic accuracy of the nerve root impinged. These results indicate that, on their own, pain patterns provide very limited additional diagnostic information about which individual nerve root is affected.

A less invasive surgery using a full-endoscopic system for L5 nerve root compression caused by lumbar foraminal stenosis.

Percutaneous endoscopic lumbar discectomy (PELD) is a relatively less invasive treatment for lumbar disc herniation (LDH). This study investigated the usefulness of a full-endoscopic system for PELD to treat L5 nerve root compression caused by lumbar foraminal stenosis (L5-LFS). Between November 2016 and December 2017, a total of 10 patients with unilateral leg pain due to L5-LFS underwent surgery using a full-endoscopic system for PELD. Patients with bilateral L5-LFS or L5-LFS with coexisting LDH and/or spondylolysis were excluded from this study. A percutaneous endoscopic translaminar approach (PETA) was performed via the ipsilateral vertebral isthmus using a 3.5-mm diameter high-speed drill. Preoperative and postoperative statuses were evaluated using the modified Japanese Orthopedic Association (mJOA) and Numerical Rating Scale (NRS) scores. The patients' mean age was 62.2 years; there were 7 male and 3 female patients. The mean recovery rate was 58.2% with the mJOA score; mean pre- and postoperative NRS scores were 7.4 and 2.3, respectively. The mean operative time was 77.6 min. Although there were no major complications, pain did not improve in an 80-year-old woman with coexisting spondylolisthesis (Meyerding grade 2). PETA using a full-endoscopic system is a safe and effective minimally invasive treatment for L5-LFS, with potential to be an alternative surgical strategy for L5-S1 interbody fusion.

PETA against left L5 nerve root compression caused by LFS

PETA against left L5 nerve root compression caused by LFS

The compression of L5 nerve root, single or double sites?-radiographic graded signs, intra-operative detect technique and clinical outcomes.

The L5 nerve root could be compressed at both L4-5 and L5-S1 regions. If L5 nerve root has confirmed compression at L4-5 level and questionable compression at L5-S1 foramina, performing both surgeries at L4-5 and L5-S1 levels may induce unnecessary extra surgery on L5-S1; however, ignoring foraminal stenosis of L5/S1 may require re-exploration. Two hundred seventeen patients with L5 nerve root compressed at L4-5 lateral access were performed with L4-5 decompression and interbody fusion. Lee et al. grade classification was used to assess the foraminal stenosis of L5-S1 preoperatively. Nerve root probe was designed and used to detect if there were foraminal stenosis at L5-S1 level that compressing the exiting L5 nerve root. Visual analog scale (VAS) of low back pain, leg pain and Oswestry Disability Index (ODI) were used to assess clinical outcomes. For all of 217 patients who underwent L4-5 surgery, L5-S1 foramina were preoperatively assessed as: grade 0: 125 cases, grade 1: 58 cases, grade 2: 23 cases, and grade 3: 11 cases. After intra-operative L5 nerve root detection, 11/11 patients with grade 3 radiographic foraminal stenosis, 6/23 (26.1%) with grade 2 and 2/58 (3.4%) who had grade 1 underwent L4-5 and L5-S1 transforaminal lumbar interbody fusion (TLIF), the others received only L4-5 TLIF. Compared to pre-operative baseline data, both L4-5 TLIF and L4-5 and L5-S1 TLIF groups had significant decreased VAS of low back pain and leg pain, and ODI at 3 and 24 months after operation. We suggested that our novel nerve root probe combined with pre-operative radiographic grade may be helpful to surgeons to identify the single or double compression of L5 nerve root and make a more precise surgical strategy to improve surgical outcome than the method depended on pre-operative radiographic grade alone.

Analysis of radiological parameters associated with decreased fractional anisotropy values on diffusion tensor imaging in patients with lumbar spinal stenosis

Previous studies have indicated that decreased fractional anisotropy (FA) values on diffusion tensor imaging (DTI) are well correlated with the symptoms of nerve root compression. The aim of our study is to determine primary radiological parameters associated with decreased FA values in patients with lumbar spinal stenosis involving single L5 nerve root. Patients confirmed with single L5 nerve root compression by transforaminal nerve root blocks were included in this study. FA values of L5 nerve roots on both symptomatic and asymptomatic side were obtained. Conventional radiological parameters, such as disc height, degenerative scoliosis, dural sac cross-sectional area (DSCSA), foraminal height (FH), hypertrophic facet joint degeneration (HFJD), sagittal rotation (SR), sedimentation sign, sagittal translation and traction spur were measured. Correlation and regression analyses were performed between the radiological parameters and FA values of the symptomatic L5 nerve roots. A predictive regression equation was established. Twenty-one patients were included in this study. FA values were significantly lower at the symptomatic side comparing to the asymptomatic side (0.263 ± 0.069 vs. 0.334 ± 0.080, P = 0.038). DSCSA, FH, HFJD, and SR were significantly correlated with the decreased FA values, with r = 0.518, 0.443, 0.472 and - 0.910, respectively (P < 0.05). DSCSA and SR were found to be the primary radiological parameters related to the decreased FA values, and the regression equation is FA = - 0.012 × SR + 0.002 × DSCSA. DSCSA and SR were primary contributors to decreased FA values in LSS patients involving single L5 nerve root, indicating that central canal decompression and segmental stability should be the first considerations in preoperative planning of these patients. These slides can be retrieved under Electronic Supplementary Material.

Diagnosis of Compressed Nerve Root in Lumbar Disc Herniation Patients by Surface Electromyography.

To establish a logistic regression model using surface electromyography (SEMG) parameters for diagnosing the compressed nerve root at L5 or S1 level in patients with lumbar disc herniation (LDH). This study recruited 24 patients with L5 nerve root compression and 23 patients with S1 nerve root compression caused by LDH from May 2014 to May 2016. SEMG signals from the bilateral tibialis anterior and lateral gastrocnemius were measured. The root mean square (RMS), the RMS peak time, the mean power frequency (MPF), and the median frequency (MF) were analyzed. The accuracy, sensitivity, and specificity values were calculated separately. The areas under the curve (AUC) of the receiver-operating characteristic (ROC) curve and the kappa value were used to evaluate the accuracy of the SEMG diagnostic model. The accuracy of the SEMG model ranged from 85.71% to 100%, with an average of 93.57%. The sensitivity, specificity, AUC, and kappa value of the logistic regression model were 0.98 ± 0.05, 0.92 ± 0.09, 0.95 ± 0.04 (P = 0.006), and 0.87 ± 0.11, respectively (P = 0.001). The final diagnostic model was: P=1-11+ey; y = 10.76 - (5.95 × TA_RMS Ratio) - (0.38 × TA_RMS Peak Time Ratio) - (5.44 × 44 × LG_RMS Peak Time Ratio). L5 nerve root compression is diagnosed when P < 0.5 and S1 nerve root compression when P ≥ 0.5. The logistic regression model developed in this study showed high diagnostic accuracy in detecting the compressed nerve root (L5 and S1 ) in these patients with LDH.

Sensitivity and Specificity of Modified Bragard Test in Patients With Lumbosacral Radiculopathy Using Electrodiagnosis as a Reference Standard

ObjectiveThe purpose of this study was to assess the diagnostic accuracy of a modified Bragard test compared with the straight leg raise (SLR) test in patients presenting with electrodiagnostic evidence of L5 and S1 nerve root compression. MethodsThis was a cross-sectional study conducted on 506 consecutive patients with signs and symptoms consistent with lumbosacral radiculopathy confirmed by electrodiagnostic study. Patients were evaluated from September 2013 to September 2015 in the physical medicine and rehabilitation outpatient clinic of Shahid Faghihi Teaching Hospital, Shiraz, Iran. The SLR test was investigated concomitantly to determine the sensitivity and specificity. ResultsElectrodiagnostic study findings indicated lumbosacral radiculopathy in 312 patients. Of these participants, 198 were positive on SLR testing, and of 114 SLR-negative patients, 79 were positive on Modified Bragard testing. Sensitivity of the Modified Bragard test was 69.3%, and specificity was 67.42%. Positive and negative predictive values were 73.15% and 63.16%, respectively. Positive likelihood ratio was 2.13, and negative likelihood ratio was 0.46. Diagnostic odds ratio was 4.63. In patients with symptom duration of less than 3 weeks, SLR sensitivity and specificity decreased as the Modified Bragard test diagnostic accuracy increased. ConclusionsThe Modified Bragard test is easy to perform and has an acceptable test performance, which can help to increase the discriminative power of clinical examination in patients with L5 or S1 nerve root compression who exhibit a negative SLR test result, especially in the acute phase of disease.

Roentgenographic and computed tomographic findings in symptomatic lumbar foraminal stenosis.

To determine the static and dynamic radiological findings characteristic of symptomatic foraminal stenosis. Between 2006 and 2011, a total of 114 patients with unilateral leg pain due to L5 nerve root compression were screened to investigate the characteristic radiological findings of symptomatic foraminal stenosis. Static findings on sagittal CT images and dynamic findings on X-rays were compared between 39 surgically treated L5-S1 foraminal stenosis patients (FS group) and 75 surgically treated L4-5 intra-spinal canal stenosis patients (CS group). There was no significant difference between the FS and CS groups in all demographic data and radiologic findings, except for the segmental range of motion in sagittal plane on functional X-rays and posterior translation on extension. The segmental range of motion in sagittal plane at L5-S1 was significantly larger in the FS group (13.4 ± 3.1 vs. 4.2 ± 2.0; p = 0.03) compared to the CS group. The prevalence of 3 mm or more posterior translation at L5 was significantly higher in the FS group (38 vs. 3%; p = 0.04) compared to the CS group, and the average posterior translation of L5 was significantly greater in the FS group (3.1 ± 1.6 mm) than that in the CS group (0.3 ± 0.6 mm) (p = 0.02). A large segmental range of motion in sagittal plane of L5-S1 and posterior instability of L5 are risk factors for symptomatic L5-S1 foraminal stenosis. These dynamic radiological findings support the diagnosis of symptomatic foraminal stenosis.

Different Sites of L5 Nerve Root Compression Cause Different Phenotypes of Sensory Deficit

Introduction Identifying the pathology responsible for the clinically presenting symptoms and signs on the image of lumbar spine is critical for a success of lumbar spine surgery. A nerve root could be compressed within the spinal canal at its preganglion segment, dorsal root ganglion, or both, depending on the pathoanatomy, such as central disc herniation, lateral recess stenosis, or foraminal stenosis. The responsible pathology required to be decompressed has a high impact on the decision of surgical strategy. For a given L5 nerve compression by central disc herniation (L4/5), a simple discectomy is capable to relieve the compression, whereas total facetectomy followed by spinal fusion is required for foraminal stenosis. Sensory deficit in lumbar radiculopathy provides a useful information helping the surgeons identifying the corresponding pathology and planing the surgical strategy. This study is devoted to elucidate the role of the phenotype of sensory deficit in different sites of nerve root compression and to see if the phenotype of sensory deficit is able to predict the compression site on the images. Materials and Methods The study prospectively included patients who had degenerative spinal disorders on L4/5 or L5/S1 levels with/without L5 radicular pain. The compressing pathologies on L5 nerve root were divided into three categories: the disc level (L4/5), the pedicle level (L5), and the foremen level (L5/S1). The sensory examination included warm, cold, static mechanical, and dynamic mechanical sensation on the foot dorsum ipsilateral to the pathology, and the foot dorsum contralateral to the pathology on the images served as the control. The association between the sensory examination and the compression sites was analyzed. Results A total of 48 patients met the inclusion criteria. The incidences of compressing pathology were 52% (25/48) in the disc level, 43% (21/48) in the pedicle level, and 20% (10/48) in the foramen level. There were 54% (26/48) patients with impaired warm sensation, 45% (22/48) with impaired cold sensation, 27.78% (10/36) with impaired static mechanical stimuli, and 39.58% (19/48) with impaired dynamic mechanical stimuli. The sensory deficit in cold or warm was highly associated with the compressing pathology at the pedicle or foramen level ( p = 0.0023) with 78.5% sensitivity and 65% specificity. Conclusion Based on our results, different sites of L5 nerve root compression caused different phenotypes of sensory deficit. One should cautiously look for compressing pathology at pedicle/foramen level if the patient presents sensory deficit. Disclosure of Interest None declared

Anatomic Variability of 120 L5 Spondylolytic Defects

Study Design Adult human osteologic specimens were assessed for spondylolytic defects and characterized. Objectives To characterize and determine the prevalence of spondylolytic defects in an osteological collection. Methods Lumbar vertebrae from the Hamann-Todd Osteological Collection at the Cleveland Museum of Natural History were examined. Digital images of specimens with L5 isthmic spondylolytic defects were analyzed, examining the distance of the pars defect in the sagittal plane in relation to the caudal aspect of the pedicle. Results There were 95 bilateral complete (BC), 16 unilateral incomplete (UI), 5 unilateral complete (UC), and 4 unilateral complete defects with an incomplete defect on the contralateral side. The mean distance of BC defects from the pedicle and inferior vertebral end plate was 4.03 mm and 4.88 mm, respectively. The mean distance of the defect from the inferior end plate on the left and right sides were 5.31 mm and 4.44 mm, respectively (p = 0.001, correlation coefficient = 0.56). The mean distance of UI and UC defects from the inferior end plate was 6.38 mm and 2.6 mm, respectively. Conclusion L5 spondylolytic defects were found in 3.87% of the sample. This large-scale description of isthmic spondylolytic defects reveals that significant variability exists in the location of the defect. The anatomic location of the pars defect likely plays a role in the development of L5 nerve root compression and radiculopathy in this clinical scenario. Classifying these defects might allow surgeons to better identify those patients who might benefit from fusion alone without posterior decompression.

Foot Drop Caused by Lumbar Degenerative Disease: Clinical Features, Prognostic Factors of Surgical Outcome and Clinical Stage

ObjectiveThe purpose of this study was to analyze the clinical features and prognostic factors of surgical outcome of foot drop caused by lumbar degenerative disease and put forward the clinical stage.MethodsWe retrospectively reviewed 135 patients with foot drop due to lumbar degenerative disease. The clinical features and mechanism were analyzed. Age, sex, duration of palsy, preoperative muscle strength of tibialis anterior (TA), sensation defect of affected lower limb, affected foot, diagnosis and compressed nerve roots were recorded and compared with surgical outcome.ResultsFoot drop was observed in 8.1% of all inpatients of lumbar degenerative disease. L5 nerve root compression was observed in 126 of all 135 patients (93.3%). Single, double and triple roots compression was observed respectively in 43, 83, and 9 patients (31.9%, 61.5%, and 6.6%). But there was no significant relationship between preoperative muscle strength of TA and the number of compressed roots. The muscle strength of TA was improved in 113 (83.7%) patients after surgery, but it reached to >=4 in only 21 (15.6%) patients. Improvement of the muscle strength of TA was almost stable at the 6-month follow-up. At the last follow-up, the muscle strength of TA was 1, 2, 3, 4, 5 respectively in 28, 24, 62, 13, 8 patients. Multivariate logistic regression showed duration of palsy (p=0.0360, OR=2.543), preoperative muscle strength of TA (p=0.0064, OR=5.528) and age (p=0.0309, OR=3.208) were factors that influenced recovery following an operation.ConclusionsL5 nerve root was most frequently affected. The muscle strength of TA improved in most patients after surgery, but few patients can get a good recovery from foot drop. Patients of shorter duration of palsy, better preoperative muscle strength of TA and younger age showed a better surgical outcome.

Lumbar foraminal stenosis causes leg pain at rest

Lumbar intra-spinal canal stenosis is characterized by leg pain that intensifies during walking and intermittent claudication, while leg pain at rest is a characteristic neurological symptom of lumbar disc herniation. Until now, a correlation between leg pain at rest and symptomatic foraminal stenosis has not been reported. This is a prospective and comparative study of unilateral leg pain from L5 nerve root compression due to spinal canal stenosis to determine clinical characteristics of lumbar foraminal stenosis. Clinical and neurological findings were compared among 38 patients receiving L5-S1 transforaminal lumbar interbody fusion for L5-S1 foraminal stenosis (FS group) and 60 patients receiving L4-5 decompression or/and fusion for L4-5 intra-spinal canal stenosis (CS group). The only significant difference between the FS and CS groups in demographic clinical data was leg pain at rest. The prevalence of leg pain was significantly higher in the FS group compared to the CS group (76 vs. 35%). The visual analogue scale for leg pain at rest was also significantly higher in the FS group than in the CS group (6.6 ± 3.1 vs. 1.3 ± 1.9). Leg pain at rest is characteristic of L5-S1 foraminal stenosis.

Compressive Symptoms Due to Thrombosed or Hypertrophic Collateral Circulation in Infrarenal Inferior Vena Cava Agenesis

Agenesis of the infrarenal segment of inferior vena cava is an uncommon and often asymptomatic congenital abnormality with an approximate incidence of 0.005-1% in the general population. Presentation of this condition as deep venous thrombosis associated with symptoms secondary to thrombosis or hypertrophy of collateral vessels is a rare clinical form. Two cases of this rare form are described, and an analysis of the related literature is presented. The first case was that of a 35-year-old man with symptoms of acute obstructive pyelonephritis with no apparent cause and swelling of the lower limb. The second case involved a 30-year-old man with lower limb swelling associated with paresthesia and motor deficit. Both patients were found to have infrarenal inferior vena cava agenesis associated with iliofemoral deep venous thrombosis and compression of anatomic structures by collateral vessels (ureteral compression due to thrombosis of an ectatic gonadal vein and L5 nerve root compression due to a hypertrophic epidural venous plexus). Patients were conservatively managed with anticoagulation therapy, with a favorable outcome and no recurrence in either case. In a young patient with iliac deep venous thrombosis of uncertain etiology, and particularly in those with atypical associated symptoms (mainly abdominal or neurologic), it is important to investigate congenital vena cava anomalies and carry out diagnostic imaging studies. Anticoagulation therapy is currently considered the best treatment option for this condition, but it should be individualized. The need for long-term anticoagulation should also be assessed in each case.

The role of capsaicin-sensitive primary afferents in experimental sciatic pain

To determine the effect of destroying capsaicin-sensitive primary afferents (CSPA) fibers on paw withdrawal mechanical threshold (PWMT) induced by the direct compression of L5 nerve root with autologous disc. The procedure used autologous disc of the rats from the coccygeal intervertebral discs to apply direct pressure to the L5 dorsal root. PWMT was measured at the different time points post-surgery and pre-surgery. The changes in spatial expression pattern of c-fos protein in the spinal cord were also determined at 3 weeks when PWMT decreased to the peak. The pretreatment with capsaicin produced a complete prevention of mechanical hyperalgesia induced by disc compression. The direct compression of L5 nerve root produced an obvious expression of fos-like immunoreactivity neurons in the dorsal horn of the spinal cord, which was significantly decreased by pretreatment with capsaicin. The study shows that CSPA fibers, which mainly terminated in superficial layers of dorsal horn, may play a key role in mechanical hyperalgesia in the new sciatica model.

Dermatome Variation of Lumbosacral Nerve Roots in Patients with Transitional Lumbosacral Vertebrae

The presence of a transitional vertebra can create difficulty in identifying the lumbar level corresponding to an exiting nerve root at the time of a spinal nerve block. We investigated the possibility that the muscle innervation pattern and sensory dermatomes of the lumbar nerve roots are altered when a lumbosacral transitional vertebra is present using electrical stimulation. We determined the existence of transitional vertebrae using Castellvi's criteria. Patients having transitional vertebrae with lumbosacral radiculopathy were recruited for the study. Selective nerve root blocks using electrical stimulation were performed. Neurologic symptoms caused by S1 or L5 nerve root compression in the patients with a lumbarized S1 or sacralized L5, respectively, were compared with those caused by either L5 or S1 nerve root compression in patients with a normal configuration. Thirty-two patients had transitional vertebrae, of whom 12 had a lumbarized S1 and 20 had a sacralized L5. The distribution of motor and sensory symptoms caused by the lumbarized S1 (L6) nerve root stimulation was similar to that of the S1 nerve root stimulation in the normal configuration. In 17 patients, the distribution of motor and sensory symptoms caused by the sacralized L4 nerve root stimulation was similar to that of L5 nerve root stimulation in the normal configuration. Our findings suggest that the function of the lumbosacral nerve roots is altered in patients with a sacralized L5, and that the L4 nerve root serves the usual function of the L5 nerve root.