L5-S1 Disc Herniation Research Articles

Case report: Anesthetic management for sequential Cesarean delivery and laminectomy

To describe the anesthetic considerations for a near-term parturient with progressive cauda equina syndrome who required Cesarean delivery followed immediately by decompression lumbar discectomy and laminectomy in the prone position. A 33-yr-old woman presented at 35 weeks gestation with severe L5-S1 disc herniation causing motor and sensory neuronal dysfunction in the lower limbs accompanied by bowel and bladder dysfunction. After urgent multidisciplinary consultations, a decision was made to proceed with general anesthesia for Cesarean delivery in the supine position with left uterine displacement, followed immediately thereafter by L5-S1 discectomy and laminectomy in the prone position. Anesthesia concerns included the risks of hemorrhage from the combined surgeries and upper airway edema from the prone position, and the physiologic changes of pregnancy. The surgeries proceeded without complication, and both mother and baby recovered uneventfully. With a multidisciplinary approach, two surgeries in two different positions with unique anesthetic considerations were performed safely under general anesthesia in advanced pregnancy in a parturient with cauda equina syndrome.

Foraminal L5–S1 disc herniation and conus medullaris syndrome: a vascular etiology?

A 56-year-old man presented with a conus medullaris syndrome lumbar magnetic resonance imaging showed only a right foraminal disc herniation at the L5-S1 level. Operative removal of the protrusion was followed by prompt neurological improvement. We postulate that the discrepancy between extent of compression shown by imaging and the neurological findings may reflect vascular compression of the artery of Desproges-Gotteron, an anatomical variant.

The importance of early postoperative radiation in spinal myxopapillary ependymomas

We read with interest the report by Aykurek et al. [1] on the success rates of combined surgical and radiation treatment of myxopapillary ependymomas. Myxopapillary ependymomas are commonly found within the cranio-spinal axis and are typically found in the caudal spinal canal, conus and cauda equina [2–4]. Total surgical extirpation has been found to a highly effective treatment in these low grade ependymomas [5, 6]. Subtotal resection of these tumors requires postoperative radiation, which has been also highly effective in preventing recurrence [5, 7]. The time frame between surgical resection and radiation therapy is yet to be fully elucidated. We recently operated on a 47 year-old male who presented for neurosurgical evaluation of an enhancing lesion within the conus. The patient was originally seen by an orthopedic surgeon for an L5-S1 disc herniation and an enhancing lesion was discovered on the preoperative MRI. The patients’ past medical history was insignificant. On neurological examination the patient had classic right S1 radiculopathy. The MRI revealed mild foraminal stenosis with a 4 mm disc bulge at L5-S1 while also demonstrating a 7 mm homogeneous contrast enhancing lesion within the conus (Fig. 1). The craniospinal axis was subsequently scanned via MRI and demonstrated no other lesions. After informed consent the patient was taken to the operating room for a microscopic L5-S1 discectomy and an L1-L2 laminectomy, durotomy for resection of conus lesion. The patient had continuous EMG and SSEP monitoring throughout the surgery. The lesion was gray in color and had several roots traversing the core of the tumor. Microdissection allowed for approximately 80% resection of the mass. Direct nerve root stimulation demonstrated several sacral roots in the core of the tumor. Postoperatively the patient was neurologically intact with full resolution of the S1 radiculopathy. The MRI performed approximately six weeks after surgery demonstrated three additional lesions cephalad to the initial surgery (Fig. 2). Further imaging of the entire craniospinal axis demonstrated no other lesions. The patient subsequently underwent stereotactic radiation therapy at a dose of 50 gy on the four lesions without complications. The metastatic potential of myxopapillary ependymomas is well documented, although not routinely recognized [8–10]. The reports of myxopapillary dissemination are reported as long as forty years ago with reports of both intracranial seeding and extraneural metastasis [3, 8–12]. Graf et al [8] report on a case of pulmonary metastasis of a myxopapillary ependymoma, although this occurred decades after the initial surgery and no focal radiation was performed after surgery. We report the first case of metastasis of myxopapillary spinal ependymoma within six weeks of initial surgery. Our case exemplifies the classic pattern of metastasis, through cerebrospinal fluid, cephalad into the ascending spinal cord. Davis et al. [3] reported two decades ago on three cases of aggressive behavior of a supposed ‘benign’ myxopapillary spinal ependymoma, speculating that a few of these tumors while R. D. Dickerman (&) A. S. Reynolds E. Gilbert B. Morgan Neurosurgery Research Foundation of Texas — Brain and Spinal Cord Tumor Institute, North Texas Neurosurgical Associates, Plano Presbyterian and Medical Center of Plano Hospitals, 6200 West Parker Road, Suite 1-503, Plano, TX 75093, USA e-mail: drrdd@yahoo.com

Retrolisthesis and lumbar disc herniation: a preoperative assessment of patient function

Background context Retrolisthesis is relatively rare but when present has been associated with increased back pain and impaired back function. Neither the prevalence of this condition in individuals with lumbar disc herniations nor its possible relation to preoperative back pain and dysfunction has been well studied. Purpose The purposes of this study were as follows: (1) to determine the prevalence of retrolisthesis (alone or in combination with other degenerative conditions) in individuals with confirmed L5–S1 disc herniation who later underwent lumbar discectomy; (2) to determine if there is any association between retrolisthesis and degenerative changes within the same vertebral motion segment; and (3) to determine the relation between retrolisthesis (alone or in combination with other degenerative conditions) and preoperative low back pain, physical function, and quality of life. Study design/setting Cross-sectional study. Patient sample A total of 125 individuals were identified for incorporation into this study. All patients had confirmed L5–S1 disc herniation on magnetic resonance imaging (MRI) and later underwent L5–S1 discectomy. All patients were enrolled in the Spine Patient Outcomes Research Trial (SPORT) study; data were obtained from the multi-institutional database comprised of SPORT patients from across the United States. Outcome measures Retrolisthesis, degenerative change on MRI, and Modic changes. Methods MRI scans of the lumbar spine were assessed at spinal level L5–S1 for all 125 patients. Retrolisthesis was defined as posterior subluxation of 8% or more. Disc degeneration was defined as any loss of disc signal on T2 imaging. Modic changes were graded 1 to 3 and collectively classified as vertebral endplate degenerative changes. The presence of facet arthropathy and ligamentum flavum hypertrophy was classified jointly as posterior degenerative changes. Results The overall incidence of retrolisthesis at L5–S1 in our study was 23.2%. Retrolisthesis combined with posterior degenerative changes, degenerative disc disease, or vertebral endplate changes had incidences of 4.8%, 16%, and 4.8% respectively. The prevalence of retrolisthesis did not vary by sex, age, race, smoking status, or education level when compared with individuals with normal sagittal alignment. However, individuals with retrolisthesis were more likely to be receiving workers' compensation than those without retrolisthesis. Increased age was found to be associated with individuals having vertebral endplate degenerative changes (both alone and in conjunction with retrolisthesis) and degenerative disc disease. Individuals who had retrolisthesis with concomitant vertebral endplate degenerative changes were more often smokers and had no insurance. The presence of retrolisthesis was not associated with an increased incidence of having degenerative disc disease, posterior degenerative changes, or vertebral endplate changes. No statistical significance was found between the presence of retrolisthesis on the degree of patient preoperative low back pain and physical function. Patients with degenerative disc disease were found to have increased leg pain compared with those patients without degenerative disc changes. Conclusions We found no significant relationship between retrolisthesis in patients with L5–S1 disc herniation and worse baseline pain or function. It is possible that the contribution of pain or dysfunction related to retrolisthesis was far overshadowed by the presence of symptoms caused by the concomitant disc herniation. It remains to be seen whether retrolisthesis will affect outcome after discectomy in these patients.

Radiculopathy after lumbar discectomy due to intraspinal retained Surgicel: clinical and magnetic resonance imaging evaluation

Background context Lumbar radiculopathy after lumbar spine surgery is an alerting sign usually caused by either a recurrent disc herniation or epidural hematoma. However, pressure on a spinal nerve root may also be exerted by a retained piece of Surgicel used to achieve hemostasis during lumbar spine surgical procedures. Purpose To describe a case of lumbar radiculopathy that was caused by a piece of Surgicel left in the spinal canal after operation for lumbar disc herniation. Study setting A case report of a retained piece of Surgicel being the cause of S1 radiculopathy. Methods Patient interview, medical records, imaging studies, and literature review. Results A 29-year-old man developed acute left S1 radiculopathy after a successful hemilaminectomy and discectomy operation for a L5–S1 disc herniation. In the magnetic resonance imaging studies that were performed, a postoperative hematoma could not be excluded and a reoperation revealed compression from Surgicel that was used for hemostasis. The patient was free of symptoms after reoperation. Conclusions This case depicts the difficulty in distinguishing—by means of magnetic resonance imaging—nerve root compression caused by a postoperative hematoma and a recurrent disc herniation, from that caused by a retained Surgicel. Therefore, hemostatic agents should be meticulously used in spine surgery.

(735): Epidural steroid injection efficacy is a function of the contrast dispersion pattern

Epidural steroid injections (ESI) may provide relief of radicular pain associated with lumbar disc herniations. Inflammation from a disc herniation occurs primarily in the ventral epidural space at the site of the disc injury. Epidural steroids should therefore, be deposited at the level of the disc lesion in the ventral epidural space. Epidural needle placement can be accomplished by one of three methods: caudal (C), translaminar (TL) or transforaminal (TF). The purpose of this study is to analyze epidurogram contrast dispersion patterns in the epidural space using the three routes of epidural needle placement. After patient informed consent and IRB approval, 60 patients with L5-S1 disc herniations were randomly assigned to have epidural steroid injections by one of three methods for epidural needle placement; caudal (n=20), translaminar (n=20) and transforaminal (n=20). Each procedure was performed with fluoroscopy using a 22 gauge Tuohoy needle. Each patient received 3 ml of iohexol 300 with 5 ml preservative saline with 40 mg of triamincolone in Groups TL and TF and 20 ml preservative saline with 40 mg steroid in Group C after proper needle placement was ascertained by epidurogram observation. Fluoroscopy was repeated at 30 min post injection. Statistical analysis was done using the Fisher Exact test with p <0.05 to reject the null hypothesis. Observed epidural contrast dispersion patterns were; V=ventral, AP =anterior-posterior and P= posterior; Caudal (n=20), V=0/20 (0%), AP=11/20(55%), P=9/20, (45%); Translaminar (n=20) V=2/20 (10%), AP= 8/20 (40%), P=10/20 (50%) and Transforaminal (n=20), V=18/20 (90%), AP, 2/20 (10%), P=0/20 (20%). Pain relief two weeks following the ESI was as follows: C, 9/20 (45%), TL, 10/20 (50%), TF, 15/20 (75%). Transforaminal ESI resulted in significantly (p<0.05) greater pain relief with a single epidural steroid injection which is attributed to a higher incidence of steroid placement within the ventral epidural space.

Significant Spinal Injury Resulting From Low-Level Accelerations: A Case Series of Roller Coaster Injuries

Freeman MD, Croft AC, Nicodemus CN, Centeno CJ, Elkins WL. Significant spinal injury resulting from low-level accelerations: a case series of roller coaster injuries. Objectives To describe a cohort of significantly injured roller coaster riders and the likely levels of acceleration at which the injuries occurred, and to compare these data with contemporary efforts to define a lower limit of acceleration below which no significant spinal injury is likely to occur. Design A retrospective case series of roller coaster ride–induced significant spinal injuries. Setting Injury incident records and emergency medical service records for the Rattler roller coaster in San Antonio, TX, were evaluated for a 19-month period in 1992 and 1993. Medical records for the more significant injuries were also reviewed and the specific injuries were tabulated, along with the demographics of the cohort. Participants There were 932,000 riders of the Rattler roller coaster, estimated to represent between 300,000 and 600,000 individual riders. Interventions Not applicable. Main Outcome Measures Injury incident reports and medical record review. Results It is estimated that there were a total of 656 neck and back injuries during the study period, and 39 were considered significant by the study inclusion criteria. Seventy-two percent (28/39) of the injured subjects sustained a cervical disk injury; 71% of these injuries were at C5-6 (15 disk herniations, 5 symptomatic disk bulges) and 54% were at C6-7 (11 disk herniations, 4 symptomatic disk bulges). In the lumbar spine, the most frequent injury was a symptomatic disk bulge (20% of the cohort), followed by vertebral body compression fracture (18%), and L4-5 or L5-S1 disk herniation (13%). Accelerometry testing of passengers and train cars indicated a peak of 4.5 to 5 g of vertical or axial acceleration and 1.5 g of lateral acceleration over approximately 100ms (0.1s) on both. Conclusions The results of this study suggest that there is no established minimum threshold of significant spine injury. The greatest explanation for injury from traumatic loading of the spine is individual susceptibility to injury, an unpredictable variable.

Isokinetic Muscle Strength of the Trunk and Bilateral Knees in Young Subjects With Lumbar Disc Herniation

Cross-sectional study comparing normal subjects and patients with lumbar disc herniation. To evaluate trunk and knee muscle strength in patients with L4-L5 and/or L5-S1 disc herniation. Numerous studies have shown that patients with low back pain have weaker trunk muscles. The strength of trunk and knee muscles has not been investigated simultaneously in patients with lumbar disc herniation. Forty-one controls and 2 patients were included. Isokinetic strength of the trunk and bilateral knees was tested on a calibrated isokinetic testing machine (Biodex System 3 Pro) regardless of the laterality of the radiculopathy. The testing was carrying out at two different velocities: 60 degrees and 120 degrees per second. Total trunk strength and knee strength were significantly lower in these patients (4.34 +/- 1.06 and 4.06 +/- 1.16 vs. 6.21 +/- 1.05 and 5.83 +/- 1.09 Nm/kg at 60 degrees and 120 degrees per second, respectively, P < 0.001). In patients with unilateral sciatica, there was no significant difference (P > 0.05) in unilateral knee strength between sciatica-involved and -uninvolved limbs (1.89 +/- 0.5, 1.08 +/- 0.45, 1.48 +/- 0.58, 0.93 +/- 0.41 vs. 1.68 +/- 0.45, 0.91 +/- 0.38, 1.41 +/- 0.48, 0.79 +/- 0.39 Nm/kg in sciatica-uninvolved vs. sciatica-involved limbs during extension and flexion at 60 degrees and 120 degrees per second, respectively). Total trunk strength was significantly correlated with total knee strength in both groups. In the patients with lumbar disc herniation, muscle strength of the trunk and knees was decreased to a similar extent. Weaker knee strength was found on either side of the lower extremity in the patients with unilateral sciatica, regardless of its location.

New treatment of lumbar disc herniation involving 5-hydroxytryptamine2A receptor inhibitor: a randomized controlled trial

Serotonin or 5-hydroxytryptamine (5-HT) is a chemical mediator associated with nucleus pulposus-induced radiculopathy. Inhibition of 5-HT receptors may potentially alleviate symptoms in patients with lumbar disc herniation. This prospective randomized controlled study was performed to evaluate the efficacy of the 5-HT2A receptor inhibitor in the treatment of symptomatic lumbar disc herniation. Forty patients with sciatica due to L4-5 or L5-S1 disc herniation were randomly allocated to treatment with the 5-HT2A inhibitor (sarpogrelate 300 mg/day) or nonsteroidal antiinflammatory drugs (NSAIDs; diclofenac 75 mg/day). Low-back pain, leg pain, and numbness were evaluated using a visual analog scale (VAS) before and after a 2-week course of treatment. The patients received only allocated medicine during the 2-week regimen and were thereafter allowed to choose any treatment options depending on their residual symptoms. One-year clinical outcomes were assessed based on the rates of additional medical interventions. The mean VAS score improvements in the 5-HT2A and NSAID groups were 33 and 46% for low-back pain, 32 and 32% for leg pain, and 35 and 22% for leg numbness, respectively. After the 2-week regimen, no additional medical interventions were required in 50% of 5-HT2A-treated patients and 15% of those receiving NSAIDs. Epidural or nerve root block procedures were performed in 35% of the 5-HT2A group and 45% of the NSAID group. Surgery was required in 20% of the 5-HT2A group and 30% of the NSAID group patients. The current study provided evidence that the efficacy of the 5-HT2A inhibitor was comparable with that of NSAID therapy for lumbar disc herniation. The 5-HT2A inhibitor has the potential to alleviate symptoms in patients with lumbar disc herniation.

Clinical and Radiological Findings of Foraminal Disc Herniation

Study Design: Retrospective study of clinical experiences. Objectives: The correct discrimination of a compressed root is very important for proper decompression. With a foraminal disc herniation, the cephalad root is compressed. The diagnostic importance of the clinical and radiological findings was investigated. Summary of literature Review: A compressed root, due to a herniated disc, is known as a caudal root (i. e. L5 root compressed by L4-5 disc herniation). In some cases, a prolapsed disc may compress the cephalad root, resulting in a difficult diagnosis. Material and Method: The medical records, plain X-ray and MRI of 17 patients were reviewed, and the physical examination and MRI findings were carefully evaluated to retrospectively document the efficacy of the diagnoses. Every MRI image of each patient was graded according to the 4 point ranking system of diagnostic efficacy devised by the authors. The clinical outcomes and postoperative complications were also investigated. Results: Ten, 5 and 2 of the 17 patients had L4-5, L5-S1 and L3-4 foraminal disc herniations, respectively. Eight of 10 L4-5 cases showed a positive femoral nerve stretching test. The knee jerk reflex was diminished in 7 patients, with bilateral hyporeflexia in the other 3. The body-cut axial MRI image was the most effective, and the coronal images were also very helpful, whereas the routine axial images were of least value. Most cases achieved a satisfactory clinical result. Conclusions: Foraminal disc herniations seem to be reasonably common. For the accurate discrimination of a compressed root, a thorough physical examination seems to be very important. When MRI is performed for these cases, in addition to routine studies, the body-cut axial and coronal MRI images are effective and useful, and their use is strongly recommended.

Chiropractic Management and Rehabilitation of a 38-Year-Old Male with an L5-S1 Disc Herniation

Objective To present a chiropractic treatment plan for a patient with lumbar disc herniation including radicular symptoms below the knee. Clinical Features A 38-year-old male experienced lumbar disc herniation with radicular symptoms to the lower extremities, below the knee. Etiology of this episode included a traumatic injury which was complicated by chronic degenerative joint and disc changes. Intervention and Outcome The treatment regime included chiropractic spinal manipulation, modalities and exercise rehabilitation. Specific rehabilitation exercises were used during various stages of healing in an attempt to stabilize a potential surgical case. Goals of care were to alleviate pain, increase function, and decrease peripheralization related to disc herniation in this case. The patient reached a level of functional biomechanical stability over 15 weeks. Conclusion This case demonstrates that with proper management, rehabilitation of a patient with disc herniation can be reached in a short duration of time.

Atypical lumbar disc herniation: a case report

Background context: This is a case report of a right posterolateral L5–S1 disc herniation that migrated to the left cephalad level to impinge on the left L5 nerve root as it exited the dura. The resultant free fragment migration is a rare variation of a posterolateral disc disruption. Purpose: The purpose is to report a rare variation of lumbar disc herniation not previously reported in the literature. Study design/setting: Case report. Patient sample: A 60-year-old white woman. Outcome measures: Resolution of the patient's left lower extremity symptoms. Methods: Not applicable. Results: The patient experienced resolution of most of her left lower extremity symptoms after a slightly modified microscopically assisted lumbar hemilaminectomy, discectomy and nerve root decompression Conclusions: This is a rare right to left migration of a sequestrated disc herniation, which was effectively treated with surgery.

Cauda equina syndrome in a 32-year-old woman following an L5-S1 central lumbar disc herniation

A 32-year-old woman with a history of chronic low back pain, hypertension, and urinary retention presented to the emergency department with left hip pain radiating to the posterior thigh, medial leg, and foot. Three days after admission, she developed cauda equina syndrome (CES) with decrease in left leg strength and sensation, as well as urinary and rectal incontinence. She was found to have a midline and left paracentral L5–S1 disc herniation on MRI and was taken to the operating room, where an L5–S1 hemilaminectomy and discectomy was performed. Her function improved almost immediately, and continued to improve after discharge from the hospital. In this report, we present a review of the literature on CES and focus on the relation between timing of surgery after the onset of CES and functional outcome.

FOOT DROP IN A MARATHONER

HISTORY - A 68 year-old male marathoner began experiencing a “floppy left foot” which “slaps the ground” after running a distance of one-half mile while training for the New York Marathon. He notes that the symptoms are present for fifteen to twenty minutes after ceasing running, and will dissipate with rest. The patient related a skiing accident three months prior in which he suffered a left hamstring injury resulting in significant swelling and ecchymosis posteriorly from the thigh to the calf. He recalls having extreme difficulty with walking, but gradually improved enough to resume training. He also had noted numbness laterally in the left lower leg for two months. He presently denies leg pain. PHYSICAL EXAM - Examination in the office revealed a pleasant male, 68 years old, conversive and friendly. Inspecton of the posterior left leg revealed no acute ecchymosis or other signs of trauma. There was a palpable fullness in the musculotendinous junction of the hamstrings, and a defect in the muscle belly 22 cm proximal to the superior popliteal crease, in which a 6 cm by 6 cm mass can also be palpated. The patient had obvious weakness graded 3+/5 to resisted knee flexion compared to his right leg, 5/5. The strength of the left tibialis anterior muscle, left extensor hallucis longus muscle, and left gastrocnemius/soleus complex were graded 4/5 versus his right leg, 5/5. The patient struggled to attain 10 toe raises on the left leg, but reached 10 on the right leg without difficulty. Sensory exam revealed subjective numbness to light touch on the lateral aspect of the left calf and the dorsolateral aspect of the left foot. DTR's were 2+ at the bilateral patellar tendons, undetectable at the bilateral hamstring tendons, and asymmetric at the achilles tendons with the left graded 1+ and the right graded 2+. DIFFERENTIAL DIAGNOSIS Hamstring tear L5-S1 disc herniation Multiple sclerosis Exertional anterior compartment syndrome Common peroneal nerve entrapment syndrome TESTS AND RESULTS MRI Lumbar spine and left thigh - extensive complete hamstring tear involving the long head of the biceps femoris, the semimembranosus, and the semitendinosus muscles. Atrophy of the involved muscles. Hematoma formation with hemosiderin adjacent to, and tethering, the sciatic nerve. - no evidence of lumbar disc herniation. EMG left leg - absent conduction of the left sural nerve and the left superficial peroneal nerve. - decreased amplitude in motor testing of the left tibial nerve. FINAL DIAGNOSIS Left sciatic nerve neuropraxia secondary to hematoma and scar tissue formation from a prior hamstring tear TREATMENT Left sciatic nerve neurolysis Physical therapy Gradual return to activity following post-op recovery

Clinical Update: Evaluation of Low Back Pain

Abstract This article provides an overview of the neurological examination and diagnostic studies commonly used in the evaluation of low back pain, information that is essential for both clinical assessment and impairment rating in the AMA Guides to the Evaluation of Permanent Impairment. Clinical evaluation begins with a careful review of medical records. After taking a thorough history, the physician performs the physical examination, including neurological testing, on the patient. The clinical evaluation also determines data needed for impairment evaluation. Neurological examination helps distinguish among the various types of pathology suggested by the history, but to some extent the neurological examination lacks sensitivity and specificity and only about two-thirds (69%) of patients with documented L4-L5 or L5-S1 disc herniations demonstrated weakness or deep tendon reflex changes. To maximize information from the evaluation, physicians routinely test for nonorganic physical signs. Isolated positive signs have no clinical or predictive value, and only a score of three or more positive signs is considered clinically significant. Further, these tests were not designed to detect malingering. Used in isolation, the history, neurological examination, and various diagnostic studies do not have the necessary sensitivity and specificity to diagnose and identify the structural pathology responsible for lumbar radiculopathy. Integrating these components into a logical, unbiased evaluation, physicians usually can perform an accurate assessment.

Abnormalities in muscle function during gait in relation to the level of lumbar disc herniation.

A comparison between gait in patients undergoing surgery for L4 and L5 lumbar disc herniations and that in an age- and weight-matched control group. To study whether changes in the moments produced at the ankle and knee joints during walking reflect the neurologic level of a herniated nucleus pulposus. Lumbar herniated discs often cause muscle weakness, reduced motor function, and change in walking capacity. The specific effects of a disc herniation on muscle function during gait is poorly documented. Conventional physical examination and kinetic analysis of gait were performed on 16 patients who subsequently underwent surgery for herniated discs (eight with L4-L5 and eight with L5-S1 disc herniations) and 16 healthy control subjects. The three components of the external moment at the ankle and knee were computed. The peak magnitudes of specific components of the external moments were compared with those of the control group. Reduced external ankle plantar flexion moment, indicating a decreased function of the ankle dorsiflexors, was found in patients with herniated nucleus pulposus of both L4-L5 and L5-S1. Reduced external ankle dorsiflexion moment, indicating a decreased function of the ankle plantar flexors, was found only in patients with a lesion to the L5-S1 disc, but not in those with herniations at L4-L5. Preoperative gait analysis identified functional deficits of the muscles about the ankle and foot that relate to the level of the herniation. Kinetic measurements can assist in understanding the functional limitations associated with specific levels of a herniation.

HAMSTRING PAIN - ADOLESCENT ATHLETE

286 DIFFERENTIAL DIAGNOSIS: 1. Hamstring strain 2. S1 radiculopathy with referred hamstring pain 3. Occult septic discitis with referred hamstring pain 4. Sacroiliac joint dysfunction with secondary hamstring tensioning TESTS AND RESULTS: LS Spine Radiographs showed straightening of the lumbar spine with no bony abnormality, or disc space or endplate changes. MRI of the LS Spine showed a moderate sized, Grade 3 disc protrusion effacing the thecal sac and impinging on the traversing S1 nerve root. FINAL/WORKING DIAGNOSIS: L5-S1 disc herniation with S1 radiculopathy and referred hamstring pain. TREATMENT: She was treated conservatively. She had a modest response to physical therapy that included traction, pool therapy, local modalities, stabilization exercises and McKenzie extensions. She is considering further interventions. HISTORY: A 15 year old female athlete complained of 3 months of gradually increasing left hamstring pain. She had no recollection of suffering any acute trauma or muscle pull, nor any bruising over the area. She reported that the pain worsened with walking on an inclined treadmill and with cycling. She denied any back pain, parasthesia or muscle weakness. There was no increase in pain with valsalva and no loss of bowel or bladder control. There was a family history of rheumatoid arthritis, but no back pain. She had IDDM which was well controlled with insulin and exercise. PHYSICAL EXAMINATION: She walked with a slightly antalgic gait. She had significant limitation of forward flexion. There was no hamstring tenderness or bruising, or pain on resisted function. She had normal reflexes, power and sensation. Straight leg raise was limited to 20 degrees on the left, with positive bowstring and Lasuage signs. Slump test was markedly positive, and knee - chest disc loading was equivocal. McKenzie extensions had no effect on her discomfort.

Chiropractic rehabilitation of a patient with S1 radiculopathy associated with a large lumbar disk herniation

Objective: To describe the nonsurgical treatment of acute S1 radiculopathy from a large (12 × 12 × 13 mm) L5-S1 disk herniation. Clinical Features: A 31-year-old man presented with severe lower back pain and pain, paresthesia, and plantar flexion weakness of the left leg. His symptoms began 5 days before the initial visit and progressed despite nonsteroidal anti-inflammatory drugs and analgesic medication. An absent left Achilles reflex, left S1 dermatome hypesthesia, and left gastrocnemius/soleus weakness was noted. Magnetic resonance imaging demonstrated a large L5-S1 disk herniation. Intervention and Outcome: Initial treatment of this patient included McKenzie protocol press-ups to reduce and centralize symptoms, nonloading exercise for cardiovascular fitness, and lower leg isotonic exercises to prevent atrophy. Counseling was provided to reduce abnormal illness behavior risk. Later, flexion distraction and side-posture manipulation were provided to improve joint function. Sensory motor training, trunk stabilization exercises, and trigger point therapy were also used. He returned to modified work 27 days after symptom onset. A follow-up, comparative magnetic resonance imaging (MRI) study was unchanged. He was discharged as asymptomatic (zero rating on both the Oswestry and numerical pain scales) after 50 days and 20 visits, although the left S1 reflex remained absent. Reassessment 169 days later revealed neither significant symptoms nor lifestyle restrictions. Conclusion: This case demonstrates the potential benefit of a chiropractic rehabilitation strategy by use of multimodal therapy for lumbar radiculopathy associated with disk herniation. (J Manipulative Physiol Ther 1999;22:38–44)

L5-S1 disc origin for a pyramidal syndrome?

The cause of pyramidal signs and symptoms is generally sought in a neurological lesion higher on the neuraxis than the peripheral lumbar roots. We decribe a case in which lumbar disc herniation was the only available explanation for these signs. A man aged 40 years with a delivery job, who had a long history of low back pain, was admitted to our unit in December, 1994, for right L5 sciatica, which started after he lifted a heavy parcel and which was aggravated after sneezing. Physical examination disclosed an important lumbar muscle contraction, which had caused severe spinal stiffness. Right leg pain was limited to the L5 metamere; Lasegue’s sign was positive at a 10o angle; no muscular weakness was noted. The patient reported symptoms suggestive of cauda-equina compression: dysuria, hypoaesthesia during urination, and no morning erections. Anal hypoaesthesia was seen on examination. Pyramidal signs included left foot epileptoid trepidation, left patella clonus, and bilateral Babinski signs. Neurological examination of the upper limbs was normal. Erythrocyte sedimentation rate was within the normal range. Computed tomography of the lumbar spine showed a huge L5-S1 lumbar-disc herniation that compressed the S1 root and the cauda equina. Spinal-cord magnetic resonance imaging and brain computed tomography showed no other lesion to explain the pyramidal signs. We performed a L5-S1 discectomy to treat the cauda equina compression and removed the free fragments. Root pain and sphincteral signs disappeared within a few hours and the pyramidal symptoms stopped within a few days. Only lumbar-root compression explained the bilateral pyramidal syndrome. Pyramidal symptoms concomitant with peripheral lumbar root pain are uncommon and may seem contradictory. Only a few cases are reported: pyramidal signs were seen in a patient with a L2–L3 herniation, and in a patient undergoing pelvic surgery after ligation of internal iliac arteries. In 1957, De Seze and colleagues reported a series of 100 patients with paralysing sciatica and offered a pathophysiological explanation. Of these patients, seven had pyramidal signs, mainly hyper-reactive tendon reflexes or patella clonus, and three had fasciculations that suggested anterior horn lesions. The investigators’ hypothesis was that peripheral root ischaemia, rather than direct, mechanical neural compression, explained the muscular weakness and the central neurological symptoms. Anatomical observation disclosed the role of the radicular arteries of the L5 and S1 roots. These arteries, located just beneath the corresponding root, irrigate these roots and, in a few patients, the filum terminale. Some researchers believe that these radicular arteries are an important component of “the anastomotic loop of the conus medullaris”. Normally, perimedullar arteries function as vascular substitution pathways, but some patients have no such arteries. L4–L5 or L5–S1 disc herniation may, therefore, compress the root and adjacent radicular arteries, leading to impaired vascularisation of the filum terminale and, thereby, to anterior horn or pyramidal signs. The relevant arteries may stem from any of several infra-aortic arteries. Their impairment may also explain spinal-cord complications sometimes seen after pelvic surgery. Although this clinical presentation of lumbar disc herniation is rare, it should be considered in the management of such patients, to avoid useless investigation that may delay emergency surgical treatment. The hypothesis of arterial impairment provides a plausible explanation. 1 Cayla J, Salliere D, Bigorie A, Pradat P. Syndrome pyramidal au cours d’une cruralgie paralysant par hernie discale L2-L3. Nouv Presse Med 1978; 7: 2482–83. 2 Kaisary AV, Smith P. Spinal cord ischemia after ligation of both internal iliac arteries during radical cystoprostatectomy. Urology 1985; 25: 395–97. 3 De Seze S, Guillaume J, Desproges-Gotteron R, Jurmand SH, Maitre M. Sciatique paralysante (etude clinique, pathogenique, therapeutique) d’apres 100 observations. Sem Hop 1957; 33: 1773–96. 4 Lazorthes G, Gouaze A, Zadeh JO, Santini JJ, Lazorthes Y, Burdin P. Arterial vascularization of the spinal cord: recent studies of the anastomotic substitution pathways. J Neurosurg 1971; 35: 253–62. 5 Parke WW, Whalen JL, Van Denmark RE, Kambin P, The infra-aortic arteries of the spine: their variability and clinical significance. Spine 1994; 19: 1–5.

Morphometric evaluation of the sacral dorsal root ganglia: A cadaveric study

An anatomic study of the sacral dorsal root ganglia (DRG) was performed to determine the location and dimensions of the S1-4 DRGs and to correlate this information to sacral nerve root ganglion lesions. S1 DRGs were located in the intraforaminal region in 55-60% and in the intracanalar region in 40-45%. S2 DRGs were in the intraforaminal region in 15-50% and in the intracanalar region in 50-85%. All the S3 and S4 DRGs were located in the intracanalar region. None of the sacral DRGs was located in the extraforaminal region. The intraforaminal position of the S1 and S2 ganglia renders them vulnerable to compression caused by sacral fractures involving the sacral foramina because of the little space available for these ganglia in the foraminal region. The S1 DRG, with its its relatively larger dimensions and its intracanalar position relative to the other sacral DRGs, may be susceptible to compression by the L5-S1 disk herniation. Its intraforaminal position may predispose it to injury during S1 or S2 pedicle screw placement.