Nerve Root Compression Research Articles

Extending the straight leg raise test for improved clinical evaluation of sciatica: validity and diagnostic performance with reference to the magnetic resonance imaging

BackgroundThe straight leg raise test (SLR) is one of the most utilized and studied physical tests in patients with low back pain (LBP) for the detection of lumbar disc herniation (LDH), showing high sensitivity and heterogeneous or low specificity. The high incidence of asymptomatic ‘pathologic’ findings in the magnetic resonance imaging (MRI) scans may cause verification bias to these results. We studied an extended SLR (ESLR) by adding location-specific structural differentiation movements (hip internal rotation or ankle dorsiflexion) to the traditional SLR for it to better differentiate neural symptoms from musculoskeletal. Previously, the ESLR has shown almost perfect interrater reliability between examiners and ability to detect sciatic patients. In this study, we investigated whether a ’positive’ ESLR finding is associated with pathology seen on MRI.MethodsForty subjects comprised the study population, 20 in sciatic group and 20 in control group. The ESLR was performed ‘blinded’ to the subjects. After the ESLR, each subject’s lumbar MRI was evaluated. The MRIs were analyzed independently by 2 senior radiologists and a spine specialist clinician. The ESLR and MRI results were cross-tabulated. To obtain the odds ratio (OR) with positive ESLR or SLR results for LDH or nerve root compression (NC), a binary logistic regression analysis with subjects’ age, gender, height and weight was performed. ESLR’s validity was assessed by combination of interrater agreement and percentage prevalence of both LDH and NC.ResultsOf sciatic (ESLR+) patients, 85 % had LDH and 75 % NC in the MRI. Not surprisingly, MRI showed a very high incidence of ‘false-positive’ findings with the ESLR negative group. The ESLR showed 0.61 sensitivity and 0.75 specificity for LDH and 0.60 sensitivity and 0.67 specificity for NC when using MRI as a reference standard. A positive result in the ESLR was found to be strongly associated with for both LDH and NC: the OR was 8.0 (p = 0.028) and 5.6 (p = 0.041), respectively.ConclusionsThe ESLR shows high validity in detecting neural symptoms and is strongly associated with pathology seen in the MRI when judged positive. We suggest the use of ESLR in clinical practice as a part of clinical examination, where it may prove to be a valuable tool in detecting patients with sciatic symptoms.

Tarlov cysts in back pain patients: prevalence, measurement method and reporting points.

Determining the prevalence of Tarlov cysts in low back pain patients. The picture archiving & communication system (PACS) & hospital information system (HIS) of a corporate hospital were retrospectively analyzed to determine the percentage of Tarlov cysts among patients undergoing spinal MRI for back pain over 3 years (January 2017 to December 2019). 384 patients had undergone spinal MRI for back pain over the study period, and 25 of them (6.51%) had Tarlov cysts. Vast majority (15 cases) showed cysts located at S2/S3 level, and few were found at S1/S2 and other levels. Single cysts were found in most (=18) of the cases, while 7 cases of multiple / bilateral cysts were found. Cyst dimensions were higher in craniocaudal than anteroposterior or transverse directions. In case of multiple cysts, one or two cysts were noted as dominant, having higher dimensions than the others. The study data revealed no gender or age predilection. We conclude that including the entire sacrum with a T2 sagittal sequence in all MRI for low back pain can increase detection of Tarlov cysts, and thereby provide more data for further analysis. We propose the concept of one "dominant" cyst when there are multiple Tarlov cysts. We recommend that diameter or size of Tarlov cysts be specified to their craniocaudal dimension. We also suggest reporting points for contextual structured reporting, viz. presence or absence of bony scalloping, neural foraminal narrowing, nerve root compression or extraforaminal extension.

Adjuvant Therapies in Metastatic Bone Disease

Bone is a common site of metastatic disease in both solid tumor and hematologic malignancies. Skeletal involvement of cancer and the complications from these metastases can produce significant morbidity including, but not limited to, pathologic fractures and pain, hypercalcemia, and spinal cord or nerve root compression with neurologic compromise. Modern therapeutic advances have been developed towards the preservation of independence and improvement in quality of life, specifically with loss of mobility and social functioning in patients with metastatic bone disease. As such, the management of bone metastases is often complex, requiring an interdisciplinary and multimodal approach among surgeons, radiation oncologists, and medical oncologists. The aim of this discussion is to highlight the current recommendations regarding adjuvant treatments – local and systemic – in metastatic bone disease, including both radiotherapy and pharmaceutical interventions.

Current Overview of Treatment for Metastatic Bone Disease.

The number of patients with bone metastasis increases as medical management and surgery improve the overall survival of patients with cancer. Bone metastasis can cause skeletal complications, including bone pain, pathological fractures, spinal cord or nerve root compression, and hypercalcemia. Before initiation of treatment for bone metastasis, it is important to exclude primary bone malignancy, which would require a completely different therapeutic approach. It is essential to select surgical methods considering the patient’s prognosis, quality of life, postoperative function, and risk of postoperative complications. Therefore, bone metastasis treatment requires a multidisciplinary team approach, including radiologists, oncologists, and orthopedic surgeons. Recently, many novel palliative treatment options have emerged for bone metastases, such as stereotactic body radiation therapy, radiopharmaceuticals, vertebroplasty, minimally invasive spine stabilization with percutaneous pedicle screws, acetabuloplasty, embolization, thermal ablation techniques, electrochemotherapy, and high-intensity focused ultrasound. These techniques are beneficial for patients who may not benefit from surgery or radiotherapy.

ELECTRODIAGNOSTIC PARAMETERS OF TIBIAL & SURAL NERVE IN LUMBAR SPINAL CANAL STENOSIS.

Background: Lumbar spinal canal stenosis (LSCS) is dened as the narrowing of the lumbar spinal canal due to bulging intervertebral discs and/or hypertrophy of the ligamentum avum and facet joints that results in the compression of nerve root that might affect the nerve conduction studies. Objective: To determine the electrodiagnostic parameters of tibial and sural nerve with and severity of lumbar spinal canal stenosis. Methods: A comparative study was conducted on 51 patients of LSCS diagnosed clinically and canal diameter measured on MRI. All patients were subjected to nerve conduction study by EMG Octopus manufactured by Clarity Medical Pvt. Ltd. Results: The mean age of participants was 49.0±16.77 years ( 22-85 years), out of which 26 (50.98%) were males and 25 (49.02%) were females. They were divided into 3 groups based on antero-posterior lumbar canal diameter for severity of stenosis. LSCS was found at multiple levels in spinal cord with most common site is LSCS in L4-L5. There was a signicant decrease in motor nerve conduction (p=0.01(Rt. & Lt. tibial)) and sensory nerve conduction (p= 0.007(Rt. sural), 0.008 (Lt. sural)) velocities. However, signicant differences in motor and sensory latencies and amplitude were not observed. Conclusion: The signicantly reduced motor and sensory nerve conduction velocities are suggestive of functional impairement of the tibial and sural nerve with the severity of LSC; however, the non signicant changes in latencies and amplitude suggests no evidence of peripheral demyelination or axonal loss.

A Comprehensive Review of Novel Interventional Techniques for Chronic Pain: Spinal Stenosis and Degenerative Disc Disease-MILD Percutaneous Image Guided Lumbar Decompression, Vertiflex Interspinous Spacer, MinuteMan G3 Interspinous-Interlaminar Fusion.

Spinal stenosis is the compression of nerve roots by bone or soft tissue secondary to the narrowing of the spinal canal, lateral recesses, or intervertebral foramina. Spinal stenosis may have acquired or congenital origins. Most cases are acquired and caused by hypertrophy of the ligamentum flavum, enlarged osteophytes, degenerative arthritis, disk herniations, and various systemic illnesses. The ligamentum flavum (LF) is a highly specialized elastic ligament that connects the laminae of the spine and fuses them to the facet joint capsules. There are a number of treatment options available for spinal stenosis. Implants and surgical interventions have grown in popularity recently, and a number of these have been shown to have varying efficacy, including the minimally invasive lumbar decompression (MILD®), Vertiflex®, Coflex® Interlaminar Stabilization, and MinuteMan G3® procedures. Minimally invasive lumbar decompression (MILD®) is a minimally invasive outpatient procedure to treat spinal stenosis related to hypertrophied ligamentum flavum. The Superion® Interspinous Spacer, also known as Vertiflex®, is a titanium implant that is delivered percutaneously to relieve back pain caused by lumbar spinal stenosis. The MinuteMan® is a minimally invasive, interspinous-interlaminar fusion device planned for the temporary fixation of the thoracic, lumbar, and sacral spine, which eventually results in bony fusion. Based on our review of the available current scientific literature, the novel interventions for symptomatic lumbar spinal stenosis, such as the MILD® procedure and the Superion® interspinous spacer, generally appear to be safe and effective. There is a possibility in the future that these interventions could disrupt current treatment algorithms for lumbar spinal stenosis.

The effect of spinopelvic parameters on transforaminal epidural steroid injection treatment success in lumbar disc herniation.

Spinopelvic parameters (SPP) is closely associated with diseases such as lumbar disc herniation (LDH), disc degeneration and spondylolisthesis. Although there exist many known clinical and radiological factors affecting the success of the transforaminal epidural steroid injection (TFESI) treatment, the effect of SPP has not yet been investigated. This study aims to examine the effects of SPP on treatment success in patients who undergo TFESI because of lumbar disc herniation and to investigate the correlation among multifidus cross-sectional area (MFCSA). This was a prospective, observational study. Patients with low back and/or leg pain, unilateral nerve root compression were applied TFESI. Outcome measures included the numerical rating scale (NRS), Oswestry Disability Index (ODI) and Beck Depression Inventory (BDI). The patients were evaluated at the first hour, third week and third month. The SPP and MFCSA measurements were made on direct radiographs and MRIs. A total of 58 patients, 24 women and 34 men, with an average age of 42.0±9.5 were included. NRS, ODI and BDI scores improved significantly up to three months follow-up (P<.001). Moderately positive correlations were found between leg NRS and PT/PI scores immediately after treatment (r: 0.307 and r: 0.334) and a weak positive correlation was found between BDI and PT at third week (r: 0.269). The MFCSA/vertebral sectional area (VSA) and MFCSA/total multifidus cross-sectional area (TMFCSA) of the affected side was found to be significantly low (P<.001). Subjects with high PI and PT reported less improvement in leg pain immediately after treatment and patients with high PT had fewer BDI improvements. MFCSA had no correlations with SPPs in patients who underwent TFESI.

THE RELIABILITY OF F-WAVE IN LUMBOSACRAL RADICULOPATHY

Lumbosacral radiculopathy is a clinical disorder caused by impaired function (compression or irritation) of lumbosacral spinal nerve roots. It is manifested by low back pain radiating down into lower limbs in a dermatomal pattern, numbness, loss or decreased reflexes and also muscle weakness along myotomal pattern may be present.There is a wide range of etiologies of lumbosacral radiculopathy, the most common etiology is spondylodegenerative changes as lumbar disc herniation.For definitive diagnosis of lumbosacral radiculopathy, there are variable diagnostic modalities which include magnetic resonance imaging of lumbosacral spine and electrophysiological studies of lower limb nerves.F wave is one of the late responses which is used to study proximal nerve involvement, it is a low amplitude response produced by antidromic activation of motor neurons.Aim of the workOur objective was to evaluate the diagnostic efficacy of F wave as an electro-diagnostic test and its reliability for diagnosing lumbosacral radiculopathy in clinically suspected patients.

Using the Compressed Sensing Technique for Lumbar Vertebrae Imaging: Comparison with Conventional Parallel Imaging.

ObjectiveTo compare conventional sensitivity encoding turbo spin-echo (SENSE-TSE) with compressed sensing plus SENSE turbo spin-echo (CS-TSE) in lumbar vertebrae magnetic resonance imaging (MRI).MethodsThis retrospective study of lumbar vertebrae MRI included 600 patients; 300 patients received SENSE-TSE and 300 patients received CS-TSE. The SENSE acceleration factor was 1.4 for T1WI, 1.7 for T2WI, and 1.7 for PDWI. The CS total acceleration factor was 2.4, 3.6, 4.0, and 4.0 for T1WI, T2WI, PDWI sagittal, and T2WI transverse, respectively. The image quality of each MRI sequence was evaluated objectively by the signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) and subjectively on a five-point scale. Two radiologists independently reviewed the MRI sequences of the 300 patients receiving CS-TSE, and their diagnostic consistency was evaluated. The degree of intervertebral foraminal stenosis and nerve root compression was assessed using the T1WI sagittal and T2WI transverse images.ResultsThe scan time was reduced from 7 min 28 s to 4 min 26 s with CS-TSE. The median score of nerve root image quality was 5 (p > 0.05). The diagnostic consistency using CS-TSE images between the two radiologists was high for diagnosing lumbar diseases (κ > 0.75) and for evaluating the degree of lumbar foraminal stenosis and nerve root compression (κ = 0.882). No differences between SENSE-TSE and CS-TSE were observed for sensitivity, specificity, positive predictive value, or negative predictive value.ConclusionCS-TSE has the potential for diagnosing lumbar vertebrae and disc disorders.

Investigational Research: Timeline, Trials, and Future Directions of Spinal Disc Arthroplasty.

Spinal disc arthroplasty (SDA) has been a rising alternative to fusion for the treatment of degenerative disc disease (DDD). This review aims to provide an overview of the timeline, approvals, and limitations of SDA through analysis of U.S. Food and Drug Administration (FDA)-approved trials. Clinical studies have shown more successful outcomes when comparing cervical disc arthroplasty (CDA) with anterior cervical decompression and fusion, with the key benefits of decreased risk of nerve root compression and adjacent disc disease. CDA is currently approved by the FDA for one- and two-level disc pathologies. However, there are no approved trials for three-level or more cervical pathologies. The FDA approved its usage for the treatment of one-level lumbar disc pathologies in 2007 and recently approved two-level disc pathologies in 2020. Thoracic SDA has not been approved by the FDA, and there are no currently occurring clinical trials. While multilevel SDA has been approved in the cervical and lumbar spine, it has not been approved in more than two adjacent vertebral levels. Based on these clinical studies, future research is needed to compare the success of SDA for three-level or more disc pathologies. There have been recent publications showing promising results, though no FDA-approved clinical trials exist. Furthermore, a hybrid construct has been a recent surgical method to treat multilevel DDD. In this approach, arthroplasty and fusion techniques are combined in alternating fashion at adjacent levels to treat two- and three-level disc disease. Hybrid arthroplasty compared with SDA is currently being studied in clinical trials. As such, long-term research with FDA-approved clinical trials is needed to understand the benefits and limitations of different approaches in the treatment of DDD.

Clinical outcomes for patients with lateral lumbar radiculopathy treated by percutaneous endoscopic transforaminal discectomy versus tubular microdiscectomy: A retrospective review

BackgroundSurgical management of lateral lumbar radiculopathy is evolving. TMD (Tubular microdiscectomy) and TELD (Transforaminal endoscopic lumbar discectomy) have emerged as viable MIS treatments. We aim to compare clinical outcomes of both techniques for the treatment of lateral lumbar radiculopathy in relation to pre-operative lumbar foraminal stenosis grade (LFS). MethodsRetrospective observational cohort study of patients with back and leg pain from single level foraminal nerve root compression that underwent TMD or TELD. Data analyzed included pre- and post-operative VAS leg and back pain, MacNab clinical outcome scores, hospital length of stay, complication rates, and operative time. Outcomes were correlated with a pre-operative MRI grading system for LFS. Results109 patients were enrolled (71 TELD and 38 TMD). Back and leg VAS pain scores improved in TELD and TMD (p < 0.0001). Patients with grade III stenosis showed significantly higher VAS scores (p < 0.01), and worse functional outcomes at latest follow-up compared with grade I/II LFS. Overall, there was no difference in outcome between procedure groups except that TMD VAS back pain scores were lower than TELD at last follow up (p < 0.05). Clinical outcome comparisons between procedures relating to LFS grade showed higher correlation of LFS to TELD (Spearman’s rho (ρ)= 0.342 for TMD and 0.606 TELD). Regression analyses demonstrated correlation between higher-grade foraminal stenosis and poorer outcomes in TELD and TMD. ConclusionsBoth TELD and TMD are viable for treating lateral lumbar radiculopathy. Higher-grade foraminal stenosis can be indicative of poorer outcomes regardless of procedure type, however, the severity of pre-operative LFS correlates with clinical outcomes in TELD more significantly than TMD.

Lower three lumbar intervertebral foramina measurements of adult Egyptians in relation to age and sex using Magnetic Resonance Imaging

Background: Intervertebral foramina(IVF) are present between adjacent vertebrae allowing connection between the vertebral canal and extra spinal elements. IVF acts as a tunnel transmitting roots of the spinal nerves and vascular structures which supply the spinal cord. Orientation of spinal cord vascularization is very important to all radiologists performing interventional procedures. Objectives: The aim of this study is to determine normal variations in dimensions of lumbar IVF at (L3- L4, L4- L5 & L5- S1) levels using Magnetic Resonance Imaging(MRI) in relation to age and sex to give basis for Egyptian measurements. Subjects and methods: Total number of studied individuals was (120) healthy individuals of both sexes with normal MRI. Subjects of study were divided into two age groups; Group(A) includes 90 persons whose ages ranged between 18-40 years old and Group(B) includes 30 persons whose ages ranged between 40-48 years old. The study was done using high field(1.5) Tesla magnetic resonance system in radiology units of Zagazig University Hospitals from April, 2017 to December, 2019. Results: Lumbar IVF dimensions were larger in the younger age group at the same levels and also larger in males than females at L3-L4 and L5-S1 levels. At L4-L5 level there was no difference in relation to age and sex. Conclusion: Application of this study can act as a data base for establishment of Egyptian measurements using MRI. IVF narrowing is responsible for different neurological symptoms that may need surgical intervention due to nerve root compression. Key words: Lumbar, intervertebral foramen, MRI, spine, measurement.

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.

Cauda Equina Syndrome: Poor Recovery Prognosis Despite Early Treatment.

A prospective patient's database operated on a cauda equina syndrome (CES). The aim of our study was to identify prognosis factors for favorable functional recovery after CES. CES is a neurologic impairment of variable symptoms associating urinary, bowel, and sexual dysfunctions with or without motor or sensitive deficits caused by nerve root compression of the cauda equina. The definition of CES remains debated, as well as the prognosis factors for favorable functional recovery and the benefit of early surgery. One hundred forty patients were included between January 2010 and 2019. Univariate and multivariate cox proportional hazard regression models were conducted. The patients were young with a median age of 46.8 years (range 18-86 yrs). At presentation, 60% were affected by a motor deficit, 42.8% a sensitive deficit, 70% urinary dysfunctions, and 44% bowel dysfunctions. The mean follow-up was 15.5 months. Bilateral motor deficit (P = 0.017) and an initial deficit severity of 0 to 2 (P = 0.001) represented prognosis factors of poor motor recovery. Initial anal incontinence (P = 0.007) was associated with poor bowel recovery. Only 32.8% of the patients went back to work. Initial motor deficit (P = 0.015), motor sequelae (P = 0.001), sphincter dysfunctions sequelae (P = 0.02), and long LOS (P = 0.02) were poor return-to-work prognosis factors. Time to surgery within an early timing < 24 or 48 hours or later did not represent a prognosis factor of recovery in CES. Incomplete versus complete CES did not show better recovery. CES remains a profound disabling syndrome with poor functional prognosis: in the long run, few patients go back to work. The main prognosis factors established in our series regarded the initial severity of deficits whether motor or sphincteral. Early or later surgical cauda equina decompression did not show to represent a prognosis factor for functional recovery.Level of Evidence: 4.

Using RNA-Seq to Explore the Hub Genes in the Trigeminal Root Entry Zone of Rats by Compression Injury

Mechanical compression on the trigeminal root entry zone (TREZ) by microvascular is the main etiology of primary trigeminal neuralgia (TN). To study the pathogenesis of TN, hub genes screening in the TREZ of TN in an animal model was performed. A double blind, randomized study was designed in a controlled animal trial. The research took place in the Laboratory of Clinical Applied Anatomy at the School of Basic Medical Science of Fujian Medical University. Twelve male rats were randomly divided into a sham operation group and a TN animal model group. TN animal model was induced by chronic compression of trigeminal nerve root (CCT) operation. Gene expression in the TREZ were analyzed by RNA sequencing (RNA-Seq) technique. KEGG analysis, GO analysis, and PPI analysis were performed in the DEGs. Key signaling pathways analyzing by GSEA and the hub genes in the DEGs were also studied. Reverse transcription real-time polymerase chain reaction (RT-qPCR) was used to verify the RNA-Seq results. Transcriptome data showed that 352 genes up-regulated and 59 genes down-regulated in DEGs on post-operation day 21, after CCT operation in the TN group. KEGG analysis revealed that, "neuroactive ligand receptor interaction" and "cytokine cytokine receptor interaction" may be related to the pathogenesis of TN. GO analysis showed "regulation of signing receptor activity", "chemokine activity", and "carbohydrate binging" may be related to TN. The RT-qPCR results were consistent with the test results, indicating that the transcriptome sequencing results were reliable. Although the incidence of TN in female rats was higher than in male rats, we only used male SD rats to establish the TN animal model, to avoid the effect of estrogen on experimental results. This study only presents some respects of RNA-Seq technique and, therefore, did not identify the DEGs at the protein level. The relationship between the DEGs at different levels shoud be done in the future. Based on the results of RNA-seq, this study discovered 6 hub genes in the TREZ that are closely related to the TN animal model, which provide a potential breakthrough point to explore the pathogenesis of TN.

SANOGENESIS OF PAIN SYNDROMES CAUSED BY DEGENERATIVE-DYSTROPHIC SPINE DAMAGE

Aim. Explore different treatment approaches for degenerative-dystrophic damage of the spine and formulate the most effective treatment methods, their stage from accounting pathogenetic basis of pain syndromes.&#x0D; Research methods – bibliosemantic, comparative, systemic.&#x0D; Results. Diverse treatments for degenerative-dystrophic damage of the spine does not facilitate but even complicates general practitioner’s work due to the fact that information on clinical benefits of various drugs and techniques as well as various types of surgery is too contradictory; there is no single method of consistent, combination therapy for vertebrogenic pain. There is no universal therapy or surgery that would provide sustainable relief of symptoms of nonspecific back pain and/or radicular syndrome. The pathogenesis of development of specific clinical manifestations of the disease and the ratio of clinical manifestations and pathomorphological changes are crucial in choosing the treatment. The general principles of treatment are unchanged: rest, analgesics and movement should be combined in appropriate sanogenic proportions in each case. Reduction of oedema and swelling of the intervertebral disc and the spinal nerve root, nerve endings are crucial in regression of pain syndrome. There is no doubt that nonsteroidal anti-inflammatory drugs (NSAIDs) are the most effective in relieving lumbar and radicular pain at the beginning of treatment. In the absence of significant improvement after the use of NSAIDs and the necessary sanogenic motor loads, a more dynamic treatment should be used. First of all, different methods of local administration of pharmacological drugs: starting with the banal subcutaneous injection of painful areas and finishing with ultrasound and MRI-controlled injections directly into the area around the damaged nerve root, the epidural space, or the facet joint. In most cases, epidural injections can reach areas of disc-radicular conflict – after the drug is injected into the epidural space, favourable conditions are created for diffusion of glucocorticoids (or other pharmacological agents) into surrounding tissues, as well as the nerve root, regardless of its compression or irritation.&#x0D; Conclusions. And only after the ineffectiveness of NSAIDs and puncture treatments, as well as epidural injection and in the case of persistent mechanical compression of nerve roots in comparison with clinical manifestations, appropriate surgical treatments, both minimally invasive and open, are necessary.

Potential Molecular Targets for Treating Neuropathic Orofacial Pain Based on Current Findings in Animal Models.

This review highlights potential molecular targets for treating neuropathic orofacial pain based on current findings in animal models. Preclinical research is currently elucidating the pathophysiology of the disease and identifying the molecular targets for better therapies using animal models that mimic this category of orofacial pain, especially post-traumatic trigeminal neuropathic pain (PTNP) and primary trigeminal neuralgia (PTN). Animal models of PTNP and PTN simulate their etiologies, that is, trauma to the trigeminal nerve branch and compression of the trigeminal root entry zone, respectively. Investigations in these animal models have suggested that biological processes, including inflammation, enhanced neuropeptide-mediated pain signal transmission, axonal ectopic discharges, and enhancement of interactions between neurons and glial cells in the trigeminal pathway, are underlying orofacial pain phenotypes. The molecules associated with biological processes, whose expressions are substantially altered following trigeminal nerve damage or compression of the trigeminal nerve root, are potentially involved in the generation and/or exacerbation of neuropathic orofacial pain and can be potential molecular targets for the discovery of better therapies. Application of therapeutic candidates, which act on the molecular targets and modulate biological processes, attenuates pain-associated behaviors in animal models. Such therapeutic candidates including calcitonin gene-related peptide receptor antagonists that have a reasonable mechanism for ameliorating neuropathic orofacial pain and meet the requirements for safe administration to humans seem worth to be evaluated in clinical trials. Such prospective translation of the efficacy of therapeutic candidates from animal models to human patients would help develop better therapies for neuropathic orofacial pain.

Presacral Ewing's sarcoma mimicking piriformis syndrome

Abstract Rationale: Piriformis syndrome is caused by entrapment or irritation of the sciatic nerve through a tight or hypertrophic piriformis muscle. Patients usually have buttock pain with sciatica. However, clinical management of piriformis syndrome is still challenging and results in repetitive investigations with potentially misleading diagnoses Patient concerns: This was a case of a thirty-six-year-old young woman, who suffered from progressive sciatica on and off for nine months. However, the symptoms progressed under conservative treatment. Diagnoses: Piriformis syndrome was diagnosed at first. Ultrasound-guided anesthetic injection over the piriformis muscle was performed, with no alleviation of symptoms. Then Magnetic Resonance Imaging revealed a space-occupying lesion over the presacral region, which was further confirmed by tissue biopsy as Ewing's sarcoma of the sacrum with right S1 and S2 nerve root compression. Interventions: The patient received neoadjuvant chemotherapy and tumor excision surgery. Outcomes: The patient was followed-up for 15 months with non-progression of residual tumor and complete resolution of sciatica. Lessons: Patients with sciatica should be evaluated by history taking and careful physical examination, followed by serial neurophysiological and imaging studies. To manage unresponsive piriformis syndrome, imaging studies should cover the pelvic and hip areas to assess the deep gluteal and pelvic region, because tumors compressing sciatic nerve can mimic piriformis syndrome. This case report aims at raising clinical awareness of the complexity of sciatica and piriformis syndrome.

Value of magnetic resonance combined with dual-source spectral computed tomography in improving the clinical diagnosis and treatment efficiency of lumbar disk herniation.

This study aims to investigate the value of magnetic resonance combined with dual-source spectral computed tomography in improving the clinical diagnosis and treatment efficiency of lumbar disk herniation. Two hundred patients with lumbar disk herniation were enrolled. Magnetic resonance and dual-source spectral computed tomography were used to perform the diagnosis. The treatment efficiency and effectiveness of different diagnostic methods were determined. Eighty cases of lumbar disk herniation, 40 cases of prolapse, 33 cases of bulge, 27 cases of sequestration, and 20 cases of nodules were diagnosed based on pathologic evaluation. magnetic resonance detected lumbar disk herniation in 172 cases, with a detection rate of 86.00%. Dual-source spectral computed tomography detected 171 cases, with a detection rate of 85.50%. Magnetic resonance combined with dual-source spectral computed tomography detected 195 cases, with a detection rate of 97.50%. There was no significant difference between magnetic resonance and dual-source spectral computed tomography (p>0.05), but compared with the combined detection, there was a significant difference (p<0.05). One hundred and two cases of calcification, 83 cases of spinal cord deformity, 70 cases of intervertebral disk degeneration, 121 cases of intervertebral disk gas, 85 cases of dural sac compression, and 78 cases of nerve root compression were surgically demonstrated. The detection rate of diagnostic signs based on imaging by magnetic resonance or dual-source spectral computed tomography alone was lower than that of combined detection (p<0.05). Magnetic resonance combined with dual-source spectral computed tomography can improve the diagnosis and treatment efficiency and effectiveness of lumbar disk herniation.

Quadriceps weakness due to disc protrusion causing nerve root compression. A case report and literature review

Most common presentation of spinal disc herniation is pain. Next common presentation is pain associated with neurological symptoms [1] . It is relatively unusual to present muscular weakness purely due to disc herniation in the absence of lower back or neuropathic pain and can be a diagnostic challenge. A male patient of 45 presented to his family physician with five days history of weakness in the left quadriceps. There was no pain in the back or leg or any sensory symptoms at this stage. There was no other significant past medical history apart of history of spontaneous disc prolapse when he was 26. (radiating pain to the left leg but no neurological symptoms at that time). Clinical examination revealed motor deficit of 4/5 in the left quadriceps and diminished knee reflex. There was no sensory deficit elicited at this stage. Patient was referred to neurologist (by this time patient had developed sensory deficit at medial lower leg) who arranged nerve conduction studies which revealed L4 radiculopathy. Patient was referred to spinal surgeon who after consultation arranged MRI of the lumbosacral spine which showed disc extrusion at L3-4 level causing root compression of L4 nerve root. Since the patient was active sportsman, it was decided to do discectomy. However, after case discussion in spinal team meeting, (and patient started to feel slight improvement in sensory symptoms after couple of weeks) it was decided to manage conservatively. Patient started physiotherapy for three months and gradually noticed complete resolution of sensory loss after a month and gradual improvement in motor weakness. Patient started light sporting activities after three months of orthopaedic consultation. Patient continued to recover and had complete resolution of motor symptoms within a year. Patient had a follow up MRI after about a year which showed subtle improvement of compression at the same level. Patient was discharged from outpatient follow up. This case illustrates diagnostic dilemma when symptoms are not typical. However, it is proven the ‘common things are common’ again. Conservative management seems to be way forward when neurological symptoms are mild especially in the absence of neuropathic pain, However, it needs to be decided on case-by-case basis