L5 Nerve Root Research Articles

Structural changes of muscle spindles in the multifidus muscle after intervertebral disk injury are resolved by targeted muscle activation.

Fibrosis of muscle spindles (sensory organs) in back muscles induced by intervertebral disc (IVD) degeneration could limit transmission of muscle stretch to the sensory receptor and explain the proprioceptive deficits common in back pain. Exercise reduces back muscles fibrosis. This study investigated whether targeted muscle activation via neurostimulation reverses or resolves muscle spindle fibrosis in a model of IVD injury. In eighteen sheep, lumbar (L)1-2 and L3-4 IVD degeneration was induced by partial thickness anulus fibrosis incision and a neurostimulator was implanted. After IVD-degeneration developed for 3 months, neurostimulation of the L2 nerve root activated multifidus in nine randomly selected animals. Multifidus muscle adjacent to the spinous process of L2 (non-stimulated) and L4 (stimulated) was harvested 3 months after activation. Muscle spindles were identified in Van Giessen's-stained sections. Connective tissue spindle capsule thickness, and cross-sectional area (CSA) of the spindle, its periaxial fluid and sensory elements were measured. Immunofluorescence assays evaluated Collagen-I and -III. Multifidus muscle spindle capsule thickness and Collagen-1 were significantly less in the neurostimulation animals than IVD-injury animals at L4 (stimulated muscle) (P < 0.05), but not L2 (non-stimulated muscle). Spindle capsule thickness was less in lateral than medial regions. CSA of the muscle spindle and sensory elements was less in neurostimulated animals at L4. Targeted multifidus activation reverses or prevents accumulation of connective tissue of the multifidus muscle spindle capsule caused by IVD injury. Reduced fibrosis should maintain sensory function of this important muscle mechanoreceptor and might provide an effective solution to resolve the commonly identified proprioceptive deficits in back pain and maintain healthy spine function.

O-Arm Navigation-Guided Unilateral Biportal Endoscopic Decompression of Far-Out Syndrome

The main aim of this video article is to demonstrate the combined use of O-arm navigation and unilateral biportal endoscopy (UBE) to manage far-out syndrome (FOS). In FOS there is entrapment and compression of the fifth lumbar nerve beyond the foramen and between L5 transverse process and the sacral ala at the lumbosacral junction. Conventional microscopic decompression using a paraspinal approach had been the gold standard for its management. However, the surgery is technically challenging due to the deep location of the pathology and intricate anatomy of extraforaminal space. There have been some published reports of unsatisfactory outcomes with microscopic decompression for FOS. We decided to integrate navigation with UBE to increase precision for the management of FOS. A 70-year-old female presented to us with chief complaint of left lower limb radiculopathy since 1 year. She also complained of numbness and paresthesias in her left leg and foot. She was unable to walk for more than 10 minutes due to pain. Her magnetic resonance imaging scan revealed compression of left L5 nerve root in the extraforaminal region. UBE decompression via paraspinal approach was performed for her under O-arm navigation. She experienced immediate relief of her symptoms in the postoperative period. O-arm-navigation-guided UBE is an effective and safer alternative to microsurgical decompression for the management of FOS. This video demonstrates the step-by-step implementation of O-arm navigation with endoscopy and its precise execution.

Evaluation of the effect of phellodendrin application on rats creating an experimental model of non-compression lumbar disc herniation on the NF-κB-related inflammatory signaling pathway

ObjectiveTo explore the therapeutic effects of phellodendrine on non-compression lumbar disc herniation (NCLDH).MethodsThe Sprague Dawley rat model of NCLDH was established via autologous caudal nucleus pulposus transplantation. Behavioral observations and neurological function scoring were conducted in Sprague Dawley rats, and the serum levels of tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) were measured via enzyme-linked immunosorbent assay (ELISA). Real-time quantitative polymerase chain reaction (RT‒qPCR) was used to detect the expression of nuclear factor kappa-B (NF-κB) p65 mRNA in L5 nerve roots and surrounding tissues. Western blotting was used to assess the protein expression of NF-κB p65 and TNF-α. Immunofluorescence and immunohistochemical analyses were performed to investigate the distribution and expression of the NF-κB p65 protein in the L5 nerve and its surrounding tissues.ResultsIn this animal study, phellodendrine was found to downregulate the expression of p65 mRNA, decrease the release of inflammatory factors, and alleviate motor dysfunction caused by lumbar disc herniation(LDH). Therefore, the phellodendrine technique has potential value for the treatment of NCLDH.ConclusionIn this animal experiment, phellodendrine was found to significantly reduce the expression level of p65 mRNA, decrease the release of inflammatory cytokines, and alleviate lumbar disc pain.Clinical trial numberNot applicable.

Variability and clinical anatomy of the superior gluteal nerve-A systematic review and meta-analysis.

The superior gluteal nerve (SGN) is a mixed nerve of the sacral plexus that arises from the posterior divisions of the L4, L5, and S1 nerve roots. Its motor branch plays a crucial role in innervation of hip muscles, which allows for physiological gait or walk-pattern. As for its sensory branch, it provides innervation for the hip joint capsule, especially its superior part. The understanding of this nerve is crucial as it may be injured during many operations involving mostly pelvic surgery, both arthroscopic and open procedures. The risk of injury is especially high during total hip arthroplasty (THA). These lesions often result in the presentation of major walk-pattern abnormalities. The most classical and commonly known would be the Trendelenburg sign, which presents with pelvic instability characterized by having the patient standing on one leg whereby the pelvis on the contralateral side will be dropping, resulting in a positive sign. The aim of this meta-analysis was to obtain all relevant data on SGN and its variations, in order to emphasize its anatomical, physiological, as well as clinical implications. A large-scale search was conducted in all major databases (PubMed, Embase, Science Direct, Google Scholar, and Web of Science) in order to determine and pool all available and relevant SGN data. No restrictions were applied to date or language. The data collection was categorized by prevalence, branching, patterns, course, origin, and distance from anatomical landmarks. A total of 41 studies (n = 869 hemipelves) were included in our analysis. The most common branching pattern of SGN was a spray pattern, 70.4% (95% CI: 54.4-96.8; p < 0.001) of the general population. We found that the closest branch to the greater trochanter of the femur and concurrently the most at risk during surgery was a muscular branch to gluteus minimus muscle. As the trend of pelvic surgeries, especially THA continues to rise, SGN lesions are now more than ever at risk. Yet to the authors' knowledge, this does not seem to be reflected in the current literature thereby making this the first meta-analysis concerning this important anatomical structure. The authors believe it is paramount for surgeons, especially in the orthopedic specialty, to thoroughly understand the SGN with its anatomical variability and clinical tie-ins.

Role of L5 Nerve Root Morphology in Identification of Lumbosacral Transitional Vertebra. Is it a Reliable Indicator?

Objective: To determine whether L5 nerve root morphology can assist in identification Lumbosacral Transitional vertebra. Study Design: Cross sectional study. Place and Duration of Study: Radiology Department, Combined Military Hospital, Multan Pakistan, Apr 2019 to Apr 2020. Methodology: Patients of both genders, 15 to 50 years age who underwent whole spine MRI were included in the study. Patients were referred from Combined Military Hospital Multan, from neighboring Combined Military Hospitals and Civil. Sagittal and axial T1WS and T2WS were performed along with coronal T2WS/FS sequences. Axial images were assessed for identification of L5 nerve root arising from LV5-SV1 level and hence vertebra was identified as LV5. Correlation was done with sagittal images for presence of Transitional vertebra, further confirmed by counting vertebral bodies from C2 vertebra upto sacrum using cross referencing tool. Results: A total of 135 patients were included in the study. Out of these, transitional vertebra was confidently labeled in 23 patients by nerve identification method which was confirmed on vertebral counting method. However, in four patients, L5 nerve root morphology was not clear and we had to rely on vertebral counting method for identification of transitional vertebra. Conclusion: Neuroanatomy and morphology of exiting L5 nerve roots can act as a reliable method for numbering of lumbosacral vertebra and identification of transitional vertebra.

Correlation between clinical and MRI findings in disc herniation in the lumbosacral region.

To compare clinical findings with MRI findings and evaluate the role of physical examination in the diagnosis, localization of the level, site, size, and type of lumbosacral disc herniation. A prospective study of 104 patients with low back pain and/or sciatica was conducted et al.-Kindy Teaching Hospital between January to December 2022. All Participants were evaluated via history, clinical examination, and MRI. One hundred patients had a disc herniation in the lumbosacral region, which was confirmed by MRI assessment after clinical presentation and physical examination. The data were collected and analyzed by the chi-square test. Most of the patients (84%) experienced pain in the lower back that radiated to the lower limb or limbs, and nearly half of the patients experienced paresthesia (48%). Sixty-six percent of the patients had a scoliotic list; limitation of lumbar spine movements was common in 96%, and a decrease in the straight leg raising test (SLR) was detected in 98%. Cross SLR "Well test" was positive in 64% of patients. The femoral nerve stretch test was positive in 40% of patients. Sixty-four percent were presented with neurological deficits, 42% with affected L5 nerve roots, 22% with affected S1 nerve roots, and no patients with L4 affected. Twenty-two percent showed a positive SLR test with an angle between 41 and 70°. Proper correlation between clinical and MRI will help determine the lesion's level, horizontal location, herniation type, and herniated disc size in the lumbosacral region and achieve a more accurate diagnosis.

Foot pressure transfers are altered in lumbar radiculopathy but reversible after surgery: a prospective, pedobarography study

BACKGROUND CONTEXTPatients with lower lumbar stenosis and disc herniation report disability in standing and ambulation, despite normal neurological examination. The L5 and S1 nerve roots support the entire motor and sensory function of the foot, and their radiculopathy can affect foot loading during standing and walking. This has not been quantified before. PURPOSETo quantify alterations in static and dynamic foot pressure transfers in patients with lower lumbar nerve root compression, and document any beneficial effects of surgical decompression. STUDY DESIGNProspective, case-control study. PATIENT SAMPLECases—Patients with unilateral radiculopathy (L5/S1) with normal neurology (n=50); Controls - Healthy volunteers (n=50). METHODSThe volunteers and patients underwent pedobarographic analysis during standing (static) and walking (dynamic), and fifteen (12 dynamic and three static) parameters were documented. The patient's preoperative values were compared with that of the healthy volunteers. All the 50 patients underwent surgical decompression, and clinical outcome measures (VAS/ODI at 3 months) were documented. Pedobarographic analysis was repeated in the postoperative period (48 hours) and 3-month follow-up and compared with the preoperative scores. RESULTSIn healthy controls, the mean values of all 15 parameters were comparable between the right and the left side (p>.05). When compared to controls, the patients had significantly lower maximum foot loads (p=.01) and average foot loads (p=.05) on the affected side during walking indicating lesser load transmission, in the preoperative period. Within the affected foot, the load transfer was higher on the first metatarsal/ medial arch while significantly less on the lateral metatarsals (p=.04). The percentage load on whole foot and forefoot was significantly less on standing (p=.01). Significant improvements were noted in the postoperative period, especially in the maximum foot surface area (p=.01), maximum and average foot loads, and improved weight transfers on lateral arch and forefoot (p=.02). The load on whole foot increased significantly from 46.1%±5.5% (preoperative) to 48.1%±5.5% (postoperative) and 49.9%±3.3% at follow-up (p=.01). CONCLUSIONThis is the first study using pedobarography to document altered foot pressure patterns during ambulation in patients with disc herniation and stenosis. Decreased load transfer, asymmetrical and unphysiological distribution of pressures on the affected foot were observed during weight bearing, which improved after surgical decompression.

Foot Tapping Test as a Simple Quantitative Index of Motor Function for Lumbosacral Radiculopathy.

We conducted a retrospective review of data from patients who underwent surgical treatment for lumbosacral radiculopathy. To assess the effectiveness of the foot tapping test (FTT) in evaluating lower limb motor function in patients with lumbosacral radiculopathy pre and postsurgery. Lumbosacral radiculopathy is becoming increasingly common in aging populations. Despite standard treatments, paralysis often leads to incomplete postoperative recovery, necessitating early detection and interventions. We enrolled individuals who underwent surgery for lumbosacral radiculopathy at our facility between 2009 and 2020. Patients with a history of lumbar surgeries, dialysis, rheumatoid arthritis, and transitional vertebrae were excluded. The FTT score was measured by having the sole of the foot tap as many times as possible for 10 seconds while keeping the heel in contact with the floor. The L4, L5, and S1 groups were assigned using the scores on the side of the radiculopathy, and the control group was assigned using the scores on the intact side. Data were analyzed using the Dunnett test for group comparisons and paired t -tests for pre and postsurgery comparisons. Of the 522 eligible patients, 80 (159 nerve roots, 1 patient with hemi-prosthetic leg) were analyzed. The preoperative FTT scores in the L4 and L5 groups were significantly lower than those in the control group, indicating functional impairment. One year postsurgery, all groups showed improvements in FTT scores, with the L5 group exhibiting significant improvements compared with the control; this was supported by the results of sensitivity analyses considering the effects of paralysis and pain. The FTT is a valuable tool for the early detection of lower limb motor dysfunction in lumbosacral radiculopathy, particularly for L5 nerve root impairment, where it aids in timely surgical intervention and may improve postoperative outcomes and quality of life.

Vacuum Disc Phenomenon Turned Gassy Disc Herniation: A Case Report

BACKGROUND: The vacuum phenomenon is a radiologic finding that results from gas accumulation within degenerated discs, joints, or vertebrae. This gas can herniate, causing back pain and/or radiculopathy. Asymptomatic imaging abnormalities can be coincidental and/or non-concordant with clinical presentation therefore warranting close evaluation. CASE REPORT: This 45-year-old man, previously diagnosed with lumbar facet arthropathy, returned to the clinic for left-sided axial low back pain. Imaging revealed that a gas filled mass in the right lateral recess was affecting the traversing right L5 and S1 nerve roots. Given the exclusive axial symptoms consistent with lumbar zygapophyseal joint arthropathy, the patient was treated with a repeat L3-4 medial branch and L5 dorsal ramus radiofrequency ablation and experienced subsequent near-complete pain resolution. CONCLUSIONS: Careful consideration must be taken when conducting clinical evaluation, imaging, diagnosis, and treatment of patients with low back pain given the significant frequency of abnormal, often nonconcordant, radiological findings. KEY WORDS: Pneumorrhachis, vacuum disc phenomenon, low back pain, case report

High Incidence of Spondylolisthesis in Patients with Grade 3 or 4 Osteoarthritis Knees with Spinal Symptoms

Abstract Introduction: The concerted radiographic incidence between lumbar degenerative spondylolisthesis (DS) and knee joint arthritis is not known. Hence, we analyzed the incidence of lumbar DS among severe knee arthritis cases in the outpatient department. Materials and Methods: In this observational study, we studied 499 patients (407 females and 92 males) with osteoarthritis (OA) of the knee. The X-rays of the lumbar spine and knee of patients were taken in a standing position. Patients with rheumatoid/ankylosing arthritis, trauma, and infection were excluded. Knee osteoarthritis was classified according to the Kellgren–Lawrence scale and spondylolisthesis was classified according to Meyerding’s classification. Results: Patients with knee osteoarthritis associated with DS were 30.9%. The statistical significance in the incidence of DS with knee osteoarthritis was found in our study. The level of DS and its relationship with the degree of OA were also studied. L5/S1 is the most prevalent level of listhesis and grade 4 OA is commonly associated with it. Conclusion: The DS incidence is significant in severe knee osteoarthritis patients. The degeneration of the lumbar spine leads to L4 nerve root pain that is relatively similar to the knee joint pain due to OA. For patients with knee pain, there is a probability of lumbar spine spondylolisthesis, so a complete examination of the spine and knee is required.

Instrumentation of hypoplastic pedicles with patient-specific guides

PurposeHypoplastic pedicles of the thoracolumbar spine (<5 mm diameter) are often found in syndromic deformities of the spine and pose a challenge in pedicle screw instrumentation. 3D-printed patient-specific guides might help overcome anatomical difficulties when instrumenting pedicles with screws, thereby reducing the necessity for less effective fixation methods such as hooks or sublaminar wires. In this study, the surgical feasibility and clinical outcome of patients with hypoplastic pedicles following pedicle screw instrumentation with 3D-printed patient-specific guides were assessed.MethodsHypoplastic pedicles were identified on preoperative computed tomography (CT) scans in six patients undergoing posterior spinal fusion surgery between 2017 and 2020. Based on these preoperative CT scans, patient-specific guides were produced to help with screw instrumentation of these thin pedicles. Postoperatively, pedicle-screw-related complications or revisions were analyzed.Results93/105 (88.6%) pedicle screws placed with patient-specific guides were instrumented. 62/93 (66.7%) of these instrumented pedicles were defined as hypoplastic with a mean width of 3.07 mm (SD ±0.98 mm, 95% CI [2.82–3.32]). Overall, 6 complications in the 62 hypoplastic pedicles (9.7%) were observed and included intraoperatively managed 4 cerebrospinal fluid leaks, 1 pneumothorax and 1 delayed revision due to 2 lumbar screws (2/62, 3.3%) impinging the L3 nerve root causing a painful radiculopathy. The mean follow-up time was 26.7 (SD ±11.7) months. Complications were only noted when the pedicle-width-to-screw-diameter ratio measured less than 0.62.ConclusionPatient-specific 3D-printed guides can aid in challenging instrumentation of hypoplastic pedicles in the thoracolumbar spine, especially if the pedicle-width-to-screw-diameter ratio is greater than 0.62.

Clinical and oncologic outcomes of posterior only total en bloc spondylectomy for spinal metastasis involving third lumbar vertebra: A case series.

A posterior-only total en bloc spondylectomy (TES) of the L3 level was deemed a highly intricate surgical procedure, necessitating the preservation of the L3 nerve root to prevent neurological deterioration. Despite bilateral preservation efforts of the L3 nerve roots, neurological deterioration proved unavoidable. This study aims to present the clinical, neurologic, and oncologic outcomes of spinal metastasis patients who underwent a posterior-only approach TES, encompassing the L3 vertebra. All patients with L3-involved spinal metastasis undergoing posterior TES between January 2018 and January 2022 were investigated. The primary outcomes considered were the local recurrence rate and manual muscle testing of the lumbar myotome. Secondary outcomes included Frankel neurological status, operative time, blood loss, perioperative and postoperative complications, and Eastern Cooperative Oncology Group score. Five patients with TES involving L3 (three females) met the inclusion criteria. All patients had solitary metastases (three in the lungs, 2 in the breasts). Postoperatively, all patients experienced weakness of the hip flexors, but they were able to ambulate independently 12 months after surgery. One patient exhibited adjacent segment (L2) disease progression and underwent corpectomy 18 months after TES. No local recurrences at the surgical site were detected on magnetic resonance imaging at the 1-year follow-up. Posterior-only TES for L3-involved vertebrae yielded excellent results in the local control of metastatic disease. Despite hip flexor weakness, all patients were able to regain independent ambulation after 12 months. TES can offer favorable clinical and oncological outcomes in patients with solitary spinal metastases.

Primary intradural extraosseous Ewing's sarcoma of the L3 nerve root: illustrative case.

Ewing's sarcoma is an uncommon, aggressive malignancy that typically presents as an osseous lesion, most commonly in children and adolescents. Very rarely Ewing's sarcoma can present as an intradural extramedullary mass mimicking more common tumors. A 32-year-old female had a left L3 nerve root-associated lesion identified in the setting of recent-onset radiculopathy. Contrast-enhanced magnetic resonance imaging of the lumbar spine was favored to demonstrate a schwannoma or neurofibroma. Hemilaminectomy, facetectomy, and resection of the mass led to improved radiculopathy and a tissue diagnosis of Ewing's sarcoma. Immediate referral to medical oncology facilitated expeditious initiation of adjuvant chemotherapy and radiation. The differential diagnosis for newly identified nerve root-associated tumors should remain broad, including common benign pathologies and rare malignant entities. Tissue remains the gold standard for diagnosis, as preoperative imaging suggested a nerve sheath tumor. Malignant pathologies such as Ewing's sarcoma must be considered, especially in the setting of rapidly progressive symptoms or interval growth on serial imaging. Early diagnosis allows for the timely initiation of comprehensive oncological care. Long-term multidisciplinary follow-up is necessary for the surveillance of disease progression.

Repeated L5 Nerve Root Compromise Detected with Motor Evoked Potentials (MEP), but Not Electromyography (EMG): A Case Report

ABSTRACT We report a case where neuromonitoring, using motor evoked potentials (MEP), detected an intraoperative L5 nerve root deficit during a lumbosacral decompression and instrumented fusion procedure. Critically, the MEP changes were not preceded nor accompanied by any significant spontaneous electromyography (sEMG) activity. Presumptive L5 innervated muscles, including tibialis anterior (TA), extensor hallucis longus (EHL) and gluteus maximus, were targets for nerve root surveillance using combined MEP and sEMG techniques. During a high-grade spondylolisthesis correction procedure, attempts to align a left-sided rod resulted in repeated loss and recovery cycles of MEP from the TA and EHL. No accompanying EMG alerts were associated with any of the MEP changes nor were MEP variations seen from muscles innervated above and below L5. After several attempts, the rod alignment was achieved, but significant MEP signal decrement (72% decrease) remained from the EHL. Postoperatively, the patient experienced significant foot drop on the left side that recovered over a period of 3 months. This case contributes to a growing body of evidence that exclusive reliance on sEMG for spinal nerve root scrutiny can be unreliable and MEP may provide more dependable data on nerve root patency.

Chapter 11 - Femoral and obturator neuropathies

The femoral and obturator nerves both arise from the L2, L3, and L4 spinal nerve roots and descend into the pelvis before emerging in the lower limbs. The femoral nerve's primary function is knee extension and hip flexion, along with some sensory innervation to the leg. The obturator nerve's primary function is thigh adduction and sensory innervation to a small area of the medial thigh. Each may be injured by a variety of potential causes, many of them iatrogenic. Here, we review the anatomy of the femoral and obturator nerves and the clinical features and potential etiologies of femoral and obturator neuropathies. Their necessary investigations, including electrodiagnostic studies and imaging, their prognosis, and potential treatments, are discussed in this chapter.

Foraminal stenosis and radiculopathy secondary to tophaceous gout: illustrative case.

Tophaceous gout is a severe form of gout that results in the formation of large nodules, or tophi, in the affected joints and surrounding tissues. Gouty tophi in the spine have a constellation of presentations that often mimic other pathologies and may not be easily discernable from more common pathologic processes. A 47-year-old female with a history of chronic renal disease, obesity, gout, inflammatory polyarthritis, and multiple sclerosis presented with 6 months of low-back pain and lumbar radiculopathy affecting the right lower extremity. A lumbar magnetic resonance imaging study revealed right foraminal stenosis and spondylolisthesis at levels L4-5. An intraspinal extradural mass was noted adjacent to the traversing right L5 and exiting right L4 nerve roots. A bilateral decompressive laminectomy, facetectomy, and foraminotomy of L4-5 was performed. A calcific, chalky-white mass was discovered in the foramen, and pathology determined the specimen to be a gout tophus. Postoperatively, the patient endorsed the resolution of her preoperative symptoms, which have not returned on follow-up. Reports of gouty depositions compressing the spinal cord in the current literature are relatively rare. Although the diagnosis of gouty tophi can only be confirmed histologically, patient history may serve as a helpful diagnostic tool.

Complications Have Not Improved With Newer Generation Robots.

Retrospective cohort study. The purpose of this study was to see whether upgrades in newer generation robots improve safety and clinical outcomes following spine surgery. All patients undergoing robotic-assisted spine surgery with the Mazor X Stealth EditionTM (Medtronic, Minneapolis, MN) from 2019 to 2022 at a combined orthopedic and neurosurgical spine service were retrospectively reviewed. Robot related complications were recorded. 264 consecutive patients (54.1% female; age at time of surgery 63.5 ± 15.3years) operated on by 14 surgeons were analyzed. The average number of instrumented levels with robotics was 4.2 ± 2.7, while the average number of instrumented screws with robotics was 8.3 ± 5.3. There was a nearly 50/50 split between an open and minimally invasive approach. Six patients (2.2%) had robot related complications. Three patients had temporary nerve root injuries from misplaced screws that required reoperation, one patient had a permanent motor deficit from the tap damaging the L1 and L2 nerve roots, one patient had a durotomy from a misplaced screw that required laminectomy and intra-operative repair, and one patient had a temporary sensory L5 nerve root injury from a drill. Half of these complications (3/6) were due to a reference frame error. In total, four patients (1.5%) required reoperation to fix 10 misplaced screws. Despite newer generation robots, robot related complications are not decreasing. As half the robot related complications result from reference frame errors, this is an opportunity for improvement.

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.

OA03 Trauma secondary to a horse riding accident as a potential accelerating factor in inflammatory axial sponyloarthropathy: a case report and literature review

Abstract Introduction Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease characterised by axial involvement and sacroiliitis. The etiology of AS remains elusive, with genetic and environmental factors implicated in disease development and progression. This case report aims to investigate the potential association between trauma and the acceleration of AS in individuals positive for HLA-B27. Furthermore one purpose of this case-report is to ascertain any link between horse riding accidents in jockeys or professionals undertaking horse riding as a career choice. Is there a correlation between trauma and development of inflammatory axial spondyloarthropathy subsequently or not. Case description A 24-year-old female patient with a medical history of eczema and Graves' disease, currently undergoing propylthiouracil treatment, was referred to the rheumatology clinic due to persistent back pain for the past six to seven years following a horse riding accident. The patient had previously received physiotherapy and found relief with naproxen and co-codamol. The pain primarily affects her lower spine and radiates down her legs. While movement provides some relief, lying down exacerbates the pain. The patient experiences stiffness for approximately 30 minutes in the morning but does not exhibit peripheral joint symptoms. Exercise helps alleviate her symptoms. The patient reported a family history of psoriasis but denied any history of uveitis, inflammatory bowel disease, weight loss, night sweats, heartblock or achilles tendinitis. She also gave a history of joint hyper mobility with reduced flexion at the spine over the years. Blood tests revealed normal levels of ANA, CCP, ESR, rheumatoid factor, B12, HbA1c, and thyroid function. Ferritin levels were 30.2, and HLA B27 was positive. Joint examination did not reveal any signs of synovitis. The patient exhibited good range of motion in the spine. SLR's were positive on both sides and no tenderness over spine or sacroiliac joints. Systemic Examination was normal. BASDAI score was 4. Occiput to wall distance of 0 centimeters. Beighton score 4/9. Subsequently MRI whole spine/SI Joints were organised and results indicated a central disc protrusion at the L4-L5 level leading to critical spinal stenosis and likely impinging on the transitioning L5 and S1 nerve roots. Additionally, a disc protrusion at the L5-S1 which was impinging on the left S1 nerve root. Bilateral sacroiliitis was also observed. Patient was treated with NSAIDs and physiotherapy with good results with a view for a subsequent MRI, and escalation to biologics if symptoms were to worsen. Discussion The presented case raises the question of whether trauma accelerates the progression of ankylosing spondylitis (AS) in individuals who are positive for HLA-B27. Although this specific case involves a 24-year-old female patient with a history of back pain following a horse riding accident, additional research and studies would be required to draw definitive conclusions regarding the relationship between trauma and the development or acceleration of AS in HLA-B27 positive individuals. The question this case report poses and there is little in terms of research and case reports present, whether the involvement of the lady in question in a horse riding accident unmasked her ankylosing spondylitis given her HLA B27 positivity and the presence of sacroilitis on MRI scans. Literature review revealed a potential role of trauma accelerating the progression of ankylosing spondylitis in individuals who are also positive for HLA B-27, in addition in some cases it lead to detection and unmasking of chronic back pain which was inflammatory in nature rather than mechanical or a combination of both. This was revealed by the horse riding accident given the nature of the pain which had been constant and worsening which lead to a suspicion of a possible inflammatory component and hence further investigations were done. In conclusion this case report highlights the importance of a possible correlation between AS in HLA B27 positive individuals and raises the question whether trauma secondary to sports injuries like horseback riding accidents in our patients case, accelerates the progression of AS in individuals who are positive for HLA-B27. Key learning points This case report highlights the potential role of trauma following a sports injury as a contributing factor in the acceleration of AS in individuals positive for HLA-B27. Further investigations, including prospective studies, are warranted to elucidate the complex interplay between trauma, genetic predisposition, and disease progression in AS. The purpose of this case report is to remind sports medicine physicians of the prevalence of rheumatologic diseases in general and ankylosing spondylitis in particular and of the various ways in which spondyloarthropathies may present in athletes/sports personnel. Increased suspicion may lead to earlier diagnosis and treatment, potentially reducing illness severity and duration and improving the performance of athletes with this condition.

Are T1-Weighted Three-Dimensional Magnetic Resonance Images Inferior to T2-Weighted Images for Diagnosing Lumbar Foraminal Stenosis in the Fifth Lumbar Nerve Root? A Prospective, Comparative Study in Identical Patients.

Imaging analysis of foraminal stenosis in the fifth lumbar (L5) nerve root remains to be a challenge because of the anatomical complexity of the lumbosacral transition. T2-weighted three-dimensional (3D) magnetic resonance images (MRI) have been dominantly used for diagnosis of lumbar foraminal stenosis, while the reliability of T1-weighted images (WI) has also been proven. In this study, we aim to compare the reliability and reproducibility of T1- and T2-weighted 3D MRI in diagnosing lumbar foraminal stenosis (LFS) of the L5 nerve root. In this study, 39 patients with unilateral L5 radiculopathy (20 had L4-L5 intracanal stenosis; 19 had L5-S foraminal stenosis) were enrolled, prospectively. T1- and T2-weighted 3D lumbar MRI were obtained from each patient. T1WI and T2WI were blinded and then separately reviewed twice by four examiners randomly. The examiners were instructed to answer the side of LFS or absence of LFS. The correct answer rate, sensitivity, specificity, and area under the curve were analyzed and compared between T1WI and T2WI. Also, intra- and interobserver agreements were calculated using kappa (κ)-statistics and compared in the same manner. The average correct answer rate, sensitivity, specificity, and area under the curve of the T1WI/T2WI were 84.6%/80.1%, 82.9%/80.3%, 86.3%/81.3%, and 0.846/0.801, respectively. The intraobserver κ-values of the four examiners ranged from 0.692 to 0.916 (average: 0.762) and from 0.669 to 0.801 (average: 0.720) for T1WI and T2WI, respectively. The interobserver κ-values calculated in a round-robin manner (24 combinations in total) ranged from 0.544 to 0.790 (average: 0.657) and from 0.524 to 0.828 (average: 0.652), respectively. As per our findings, T1- and T2-weighted 3D MRI were determined to have nearly equivalent reliability and reproducibility in terms of diagnosing LFS of the L5 nerve root.