Onset Of Leg Pain Research Articles

85. Incidence and resolution strategies for early onset postoperative leg pain following lumbar total disc replacement

BACKGROUND CONTEXT Lumbar total disc replacement (TDR) was introduced in the 1980s and is becoming more common. Anecdotally, there have been reports of patients reporting the onset of new leg pain following TDR surgery. To date, there has been little formal investigation into this clinical phenomenon. PURPOSE The purpose of this study was to determine the incidence of new-onset leg pain following lumbar TDR and investigate treatment strategies for this occurrence. STUDY DESIGN/SETTING This study was based on a post hoc analysis of data collected prospectively as part of an FDA IDE trial. PATIENT SAMPLE The study population was comprised of 283 patients who received ProDisc-L or activL® as part of the multicenter, randomized FDA IDE trial for the latter device. Patients were treated for symptomatic single-level disc degeneration unresponsive to at least 6 months of nonoperative care. OUTCOME MEASURES The primary outcome measures in the study were the onset of leg pain following TDR surgery and the outcomes of treatments for this condition. METHODS New onset of leg pain following TDR surgery was identified from adverse event reports collected prospectively during the trial. It was defined as leg pain beginning 0- to 4 weeks postoperatively. The treatment of these symptoms was at the operating surgeon's discretion. Treatment strategies were classified as: medication, nonoperative care, injections, and/or subsequent surgery. RESULTS New onset of postoperative leg pain occurred in 9.2% of lumbar TDR patients (26/283). The new onset pain resolved in 76.9% (20/26) of patients. Most patients (24 of 26) were treated with one or more medications, the most common of which was anticonvulsant drugs such as gabapentin or pregabalin, commonly used to treat neurogenic-type pain. Symptoms resolved in 75% of patients receiving this type of medication. Some also received narcotics and 30.8% were treated with steroids, most commonly a Medrol dose-pack. Twelve patients received other nonoperative care (PT, acupuncture, etc.) and 7 received injections. Three patients went on to have subsequent surgery, none of whom had resolution of the new onset leg pain after the additional procedure. Among the 20 patients whose new symptoms resolved, resolution occurred within 3 months in 11 patients. CONCLUSIONS Early-onset postoperative leg pain occurred in approximately 10% of lumbar TDR patients. The source of the symptoms is not clear. In the majority of patients, the new symptoms resolved, often within 3 months of onset. While challenging to definitively evaluate in this relatively small subset of patients, it appears the most effective treatment strategy is gabapentin or pregabalin. The role of other nonoperative interventions could not be discerned. Surgical re-intervention is likely unnecessary and did not lead to resolution of early onset leg pain post-TDR. FDA DEVICE/DRUG STATUS activL and ProDisc-L (Approved for this indication).

Association of time to surgery with leg pain after lumbar discectomy: is delayed surgery detrimental?

While it has been established that lumbar discectomy should only be performed after a certain waiting period unless neurological deficits are present, little is known about the association of late surgery with outcome. Using data from a prospective registry, the authors aimed to quantify the association of time to surgery (TTS) with leg pain outcome after lumbar discectomy and to identify a maximum TTS cutoff anchored to the minimum clinically important difference (MCID). TTS was defined as the time from the onset of leg pain caused by radiculopathy to the time of surgery in weeks. MCID was defined as a minimum 30% reduction in the numeric rating scale score for leg pain from baseline to 12 months. A Cox proportional hazards model was utilized to quantify the association of TTS with MCID. Maximum TTS cutoffs were derived both quantitatively, anchored to the area under the curve (AUC), and qualitatively, based on cutoff-specific MCID rates. From a prospective registry, 372 patients who had undergone first-time tubular microdiscectomy were identified; 308 of these patients (83%) obtained an MCID. Attaining an MCID was associated with a shorter TTS (HR 0.718, 95% CI 0.546-0.945, p = 0.018). Effect size was preserved after adjustment for potential confounders. The optimal maximum TTS was estimated at 23.5 weeks based on the AUC, while the cutoff-specific method suggested 24 weeks. Discectomy after this cutoff starts to yield MCID rates under 80%. The 24-week cutoff also coincided with the time point after which the specificity for MCID first drops below 50% and after which the negative predictive value for nonattainment of MCID first surpasses ≥ 20%. The study findings suggest that late lumbar discectomy is linked with poorer patient-reported outcomes and that-in accordance with the literature-a maximum TTS of 6 months should be aimed for.

Obscure Severe Infrarenal Aortoiliac Stenosis With Severe Transient Lactic Acidosis.

A 57-year-old man presented with sudden onset of leg pain, right-sided weakness, aphasia, confusion, drooling, and severe lactic acidosis (15 mmol/L). He had normal peripheral pulses and demonstrated no pain, pallor, poikilothermia, paresthesia, or paralysis. Empiric antibiotics, aspirin, full-dose enoxaparin, and intravenous fluid were initiated. Lactic acid level decreased to 2.5 mmol/L. The patient was subsequently extubated and was alert and oriented with no complaints of leg or abdominal pain. Unexpectedly, the patient developed cardiac arrest, rebound severe lactic acidosis (8.13 mmol/L), and signs of acute limb ischemia. Emergent computed tomography of the aorta confirmed infrarenal aortoiliac thrombosis. Transient leg pain and transient severe lactic acidosis can be unusual presentations of severe infrarenal aortoiliac stenosis. When in doubt, vascular studies should be implemented without delay to identify this catastrophic diagnosis.

Acute non-traumatic compartment syndrome of anterior compartment of leg; an unusual presentation: A case report

2. Case report50-year-old male, a cottage industry owner, presented at 02:00complainingoffeelingcold,shiveringandwithseverepaininrightleg. He had no prior history of leg pain. The previous morning hehad played football for the first time for 15 min when the outsidetemperaturewasabouttwodegreecelsius.Hehad nofall,twistingof leg/foot, or direct trauma to the leg. Throughout the day he hadperformed his routine activities without any discomfort or pain.Approximately 12 h laterhestartedfeeling cold. Hewas putunder5layersofblanketswhichdidnothelpandtheshiveringpersisted.Within anhourhedeveloped paininright legand lowerabdomen.He vomited twice and passed loose stools once.Oral NSAID’S prescribed by a GP did not relieve his pain.AnotherGPgaveananalgesicinjectionalongwithatranquiliser.Asthe pain persisted he presented to the emergency services.He was afebrile. Local examination revealed a swollen, wood-hard, tender, anterior compartment of the leg with dilatedsuperficial veins (Figs. 1 and 2). Passive dorsiflexion of the toesand ankle were painful. Extensor hallucis longus and extensordigitorum longus had grade 1/5 motor power and tibialis anteriorgrade 2/5. The dorsum of the foot had hypoesthesia. Dorsalis pedisand posterior tibial pulses were well palpable.Baseline haematocrit and biochemistry values were withinnormal limits. The radiographs were normal.The patient was immediately taken to theatre for decompres-sion. Fasciotomy by Mubarak’s single longitudinal lateral incisionwas done within 6 h of onset of leg pain.

Intraspinal cross-section areas measured on myelography--computed tomography. The relation to outcome in nonoperated lumbar disc herniation.

A prospective cohort study with computed tomographic-myelographic and clinical base registrations and follow-up by questionnaire 14 months after the onset of leg pain. To detect predictive relations between intraspinal area measures and outcome in nonoperated lumbar disc herniation. Myelography and computed tomography are qualitative methods ordinarily. The authors wanted to investigate the quantitative possibilities of computed tomographic technology in the pursuit of predictive measures. Cross-section areas of the disc hernia, the dural sac, and the residual spinal canal were measured on computed tomography-myelography in 58 patients with lumbar disc herniation who did not undergo surgery. Pain, disability, and vocational status were asked for in a questionnaire after 8 months. After a median of 14 months from the onset of leg pain, 77% had returned to work, and only 7% were pain-free. The hernia size was not associated with the outcome measures. A high score for pain intensity and distal pain distribution was associated with a wide dural sac and a wide residual spinal canal. Disability and vocational status were not associated with any of the areas measured. Patients with the longest duration of leg pain had the narrowest spinal canals. Area measurements on computed tomography-myelography could not predict outcome in patients with lumbar disc herniation who were not operated on. There was an association between pain and a wide dural sac, which might underscore the sensory role of dura in protracted cases of sciatica.

Onset of Intolerance Symptoms during Exercise Testing Is a Reproducible Threshold for Evaluation of Cardiac Function

Twenty-one male patients with a history of myocardial infarction underwent bicycle cardiopulmonary exercise testing. The onset of leg pain or dyspnea, which reflects anaerobic metabolism, was termed anaerobic exercise symptom threshold (AEST). Our aims were (1) to evaluate the temporal relationship between AEST and the ventilatory anaerobic threshold (VAT) and (2) to determine whether heart rate, rate-pressure product, exercise time, and the ventilatory parameters at AEST are reproducible and correlate with the same parameters at VAT. AEST overlapped VAT in 4 patients and lagged behind VAT in 15. AEST never preceded VAT. The mean exercise time at VAT was 4.1 +/- 1.2 min and at AEST 5.6 +/- 1.6 min (p < 0.0001); the mean heart rate was 97 +/- 10 and 107 +/- 12, respectively (p < 0.001). The mean values of the rate-pressure product and the oxygen consumption at AEST were significantly higher than at VAT. The correlation coefficient ranged from r = 0.74 to r = 0.93. Fifteen patients were examined twice within 1 month; the above parameters were reproducible at AEST, VAT, and peak exercise. In conclusion, AEST, which is easily recorded during bicycle exercise testing, is useful as a reference point for evaluation and follow-up of the cardiac aerobic function.

Atheromatous Microembolism Simulating Polymyositis

A case of atheromatous microembolism to the lower extremities illustrated some typical findings: sudden onset of leg pain, cool legs with normal peripheral pulses, petechiae, livedo reticularis, and elevated, tender nodules which represented muscle necrosis. The dominant clinical picture was consistent with acute polymyositis. Diagnosis of atheromatous microembolism with muscle necrosis was confirmed by muscle biopsy.