Positive Straight Leg Raising Test Research Articles

Characteristics in patients with very early therapeutic response of condoliase chemonucleolysis for lumbar disc herniation.

Treatment of lumbar disc herniation (LDH) using condoliase chemonucleolysis (CC) requires more time than surgery to demonstrate therapeutic effects. This study aimed to identify patients who show significant improvement in leg pain very early after CC and to determine pretreatment factors that can predict a very early therapeutic response. The study included 52 patients who underwent CC for treatment-resistant LDH. Scores for low back and leg pain measured by a numerical rating scale were assessed at four time points (1day, 1 week, 1 month, and 3 months after CC). Patients who reported subjective pain relief the day after treatment and further exhibited an improved straight leg raising (SLR) angle compared to pretreatment were classified as "very early responders (VER)". Of the 52 patients, 39 (75%) were VER, and 13 (25%) were non-VER. The VER showed earlier improvement in leg pain. The VER had a significantly higher proportion of positive SLR test patients (p = 0.01) and a significantly smaller pretreatment SLR angle compared to the non-VER (VER vs. non-VER: 40.6 ± 19.0 vs. 63.1 ± 16.9, p < 0.001). There were no significant differences in the level, type, and size of LDH and the disc regression rate between the two groups. Patients with a smaller pretreatment SLR angle are more likely to experience very early or early symptomatic relief, with a significant and sustained reduction in leg pain up to 3 months after CC treatment.

Conservative Treatments for Lumbar Disc Herniation at L3-4 or L4-5 Were More Likely to Fail When Ipsilateral Foraminal Stenosis Was Present at the Caudally Adjacent Segment

Conservative treatments are important in lumbar disc herniation (LDH), but predictors for poor outcomes are unclear. Consecutive patients with unilateral single-level LDH at L3-4 or L4-5 were enrolled. Baseline clinical data were collected, and lumbar spine magnetic resonance imaging was evaluated. Foraminal stenosis was evaluated using Lee's approach and further categorized as absence (grade 0 and 1) or presence (grade 2 or 3). Each patient underwent conservative treatments (oral meloxicam and dexamethasone, corset, back extension exercise, physiotherapy, and manual therapy) for 6 weeks. Conservative treatments were defined as failed if a patient underwent surgery within 6 weeks or reported poor recovery at 6-week follow-up. Multivariate logistic regressions were used to examine the associations of failed conservative treatments with baseline characteristics and magnetic resonance imaging findings. The study included 222 patients (mean age 45.5 ± 9.8 years). Of patients, 48 (21.6%) had concurrent ipsilateral foraminal stenosis at the caudal segment, and conservative treatments failed in 39 (17.6%). At baseline, patients with LDH and caudal foraminal stenosis were older (50.79 ± 6.14 years vs. 44.10 ± 10.13 years, P < 0.001), had greater leg pain (7.06 ± 1.17 vs. 6.39 ± 1.40, P= 0.003), and had a higher rate of positive straight leg raising test (54.2% vs. 33.3%, P= 0.008) than patients without caudal foraminal stenosis. In multivariate regression, failure of conservative treatments was associated with positive straight leg raising test (odds ratio 2.26, P= 0.046), and caudal foraminal stenosis (odds ratio 3.20, P= 0.007). In the presence of caudal foraminal stenosis and positive SLR test, conservative treatments were more likely to fail in patients with LDH.

Predictors of the conservative management outcomes in patients with lumbar herniated nucleus pulposus: A prospective study in Indonesia

BackgroundThe objective of this study was to identify the predictors of the conservative management outcomes in patients with lumbar herniated nucleus pulposus (HNP). MethodsA prospective study was conducted between June 2010 and April 2012 in Banda Aceh, Indonesia. Clinical and baseline neurologic examinations such as passive straight leg raising test (SLRT), cross SLRT, and patellar and Achilles reflexes were assessed prior to the conservative management. The patients were evaluated at 2nd, 4th, 8th, 12th and 24th week following commencement of the conservative management. ResultsWe recruited and followed 171 HNP patients of which 35.7% of them had good outcome. At univariate analysis, patients with more than 12 months duration of complaint, those with dominant radicular pain, severe pain intensity (visual analogue scale 7–10), positive SLRT, positive cross SLRT, and reduced motor power of knee extensors (muscle strength grade 1–4), were associated with poor outcome. Multivariate analysis suggested that patients with dominant radicular type of pain were likely to had poor outcome compared to those with dominant back pain (odd ratio (OR) 10.57 with 95% confidence interval (CI) 1.15–96.93). Patients with reduced motor power of knee extensors also had a higher chance to have poor outcome compared to those who were normal (OR: 10.57; 95% CI: 1.15–96.93). ConclusionType of pain and the strength of lower extremities could be able to predict the failure of conservative management in patients with lumbar disc herniation. However, further studies with the bigger sample size are warrant to validate our results.

Sciatic scoliosis: An easily misdiagnosed disease in adolescents and young adults

ObjectiveThis study aimed to analyze the clinical presentation and surgical outcome of scoliotic listing due to herniated intervertebral disc in adolescents or young adults, and making a differential diagnosis between sciatic scoliosis and idiopathic scoliosis. Materials and MethodsThis retrospective review focused on a group of five adolescents or young adults with herniation of the intervertebral disc who initially presented scoliotic posture between January 2005 and September 2011. The history, physical examination, imaging studies, and operative findings were recorded and analyzed. ResultsThree males and two females, with a mean age of 17.3 years (range, 14–24 years), were enrolled in our study. All of them had been misdiagnosed as having idiopathic scoliosis and had been treated for this for several months. All had a positive straight leg raising test (SLRT) result between 30° and 60° prior to surgery, which improved to 80° after surgery. In all five cases, the convexity of scoliosis was at the same side of the disc herniation. The Cobb angle in all patients improved after surgery (mean, 26.9° preop to 11° postop). ConclusionIt is important to obtain a detailed history, and to perform a physical examination (positive SLRT) and imaging studies (lack of vertebral rotation in the standing anterior–posterior radiographs) in adolescents or young adults with painful scoliosis, which may help us make a differential diagnosis from idiopathic scoliosis.

Comparison of E-selectin and the Other Inflammatory Markers in Lumbar Disc Herniation

Histopathologic and immunohistochemical analysis of the herniated disc specimens obtained from 50 patients who had unilateral persistent radicular pain or unilateral radicular motor paresis. The aim of this study was to investigate the prevalence of inflammatory cells in lumbar disc herniations (LDH) and compare the prevalence of leukocyte adhesion protein "E-selectin" with other inflammatory cells such as T cells, B cells, and macrophages. Studies on inflammatory cells and biochemical mediators of inflammation have suggested that these factors may play an important role in pathophysiology of radicular pain, and the medical therapy was formed against to block these cells and inflammatory cytokines. The herniated disc specimens obtained from 50 patients who had unilateral persistent radicular pain or unilateral radicular motor paresis were microscopically examined after staining with monoclonal antibodies of CD20, CD45, CD68, and E-selectin. Relative risk assessment of the straight-leg raising (SLR) test positivity or negativity with CD20, CD45, CD68, and E-selectin staining was investigated. Our data emphasize that, the cases with positive SLR test had higher rates of immunostaining with E-selectin and CD45. There were no statistically significant relationship between SLR positivity and CD20 and CD68. We suggest that E-selectin is as valuable as the other well-known inflammatory markers in the pathogenesis of LDH. In our opinion, beside the well-known nonsteroidal anti-inflammatory drugs, antagonists targeting E-selectin can be potentially effective therapeutics for controlling inflammation in LDH.

Utility of single photon emission computed tomography/computed tomography imaging in evaluation of chronic low back pain

Introduction:Abnormal morphologic findings in imaging were thought to explain the etiology of low back pain (LBP). However, it is now known that variety of morphologic abnormalities is noted even in asymptomatic individuals. Single photon emission computed tomography/computed tomography (SPECT/CT) could be used to differentiate incidental findings from clinically significant findings.Objective:This study was performed to define the SPECT/CT patterns in patients with LBP and to correlate these with clinical and magnetic resonance imaging (MRI) findings.Materials and Methods:Thirty adult patients with LBP of duration 3 months or more were prospectively evaluated in this study. Patients with known or suspected malignancy, trauma or infectious processes were excluded. A detailed history of sensory and motor symptoms and neurologic examination was performed. All the patients were subjected to MRI and bone scintigraphy with hybrid SPECT/CT of the lumbo-sacral spine within 1 month of each other. The patients were classified into those with and without neurologic symptoms, activity limitation. The findings of clinical examination and imaging were compared. MRI and SPECT/CT findings were also compared.Results:Thirty patients (18 men and 12 women; mean age 38 years; range 17-64 years) were eligible for the study. Clinically, 14 of 30 (46%) had neurologic signs and or symptoms. Six of the 30 patients (20%) had positive straight leg raising test (SLRT). Twenty-two of the 30 patients (73%) had SPECT abnormality. Most frequent SPECT/CT abnormality was tracer uptake in the anterior part of vertebral body with osteophytes/sclerotic changes. Significant positive agreement was noted between this finding and MRI evidence of degenerative disc disease. Only 13% of patients had more than one abnormality in SPECT. All 30 patients had MRI abnormalities. The most frequent abnormality was degenerative disc disease and facet joint arthropathy. MRI showed single intervertebral disc abnormality in 36% of the patients and more than one intervertebral disc abnormality in remaining 64% patients. Fifteen of the 30 patients had facet joint arthropathy. 60% of these patients had involvement of more than one level facet joints while 38% had associated inter vertebral disc disease. 83% of the patients with positive SLRT had SPECT and MRI abnormalities. 100% of patients with neurologic symptoms had SPECT and MRI abnormalities.Conclusion:Addition of hybrid SPECT/CT data will help differentiate incidental from significant MRI abnormalities as all patients with LBP have MRI abnormalities and most have MRI abnormalities at multiple sites. Tracer uptake in the anterior part of the vertebral body represents degenerative disc disease. MRI is sensitive and SPECT/CT is specific for facet joint arthropathy. Both investigations are best used complementary to each other.

A study of the relationship between type of lumbar disc herniation, straight leg raising test and peripheral T lymphocytes.

To observe changes in peripheral T lymphocytes of patients with lumbar disc herniation, and investigate the relationship between the type of herniation, signs and T lymphocyte subsets. Blood samples from 20 healthy blood donors (control group), and 49 patients (27 male and 22 female) with single-level lumbar intervertebral disc herniation were collected, the latter preoperatively. T lymphocytes subsets were detected by flow cytometer. According to the position of the intervertebral disc observed during surgery, the patients were divided into ruptured disc herniation (RDH) and degenerative disc herniation (DDH) groups. Straight leg raising (SLR) was assessed preoperatively. Percentages of CD3+, CD4+, and ratio of CD4+/CD8+ in the RDH group were significantly higher, and of percentage of CD8+ significantly lower, than were those in the control group. Percentages of CD4+ and ratio of CD4+/CD8+ were significantly higher, and percentage of CD8+ significantly lower, in the positive SLR test group than were those in the negative SLR test group. The positive rate of SLR testing was significantly higher in the RDH than in the DDH group. Our results suggest that changes in T lymphocyte subsets in peripheral blood take place after herniation of the lumbar intervertebral disc. T lymphocyte mediated immune responses may play an important role in the occurrence and development of signs in patients with herniated lumbar intervertebral discs. The SLR test may help to confirm that disc herniation has caused nerve root impairment by mechanical loading or inflammatory stimulus and provide guidance on the choice of treatment.

Perineural Cyst as a Rare Cause of L5 Radiculopathy

To the Editor: We report a rare case presenting with a cyst that was observed in the lumbar spine and caused L5 radiculopathy. A 34-yr-old woman presented with a 6-yr history of left lower back pain and left lower extremity pain. Physical examination was unremarkable except for a positive straight leg-raising test on the left side. Magnetic resonance imaging (MRI) was reported to be within normal limits except for slightly bulging discs at L4–5 and L5–S1 (Fig. 1). No lumbosacral transitional vertebrae were identified. Several epidural blocks decreased pain but left L5 radiculopathy remained. L5 selective nerve root block alleviated pain temporarily. Epidurography showed a filling defect in the L5 vertebral level. We suspected the presence of epidural adhesions and performed diagnostic epiduroscopy. The endoscope was introduced into the sacral hiatus and advanced into the epidural space but could not be advanced into the area of the filling defect. We realized a space-occupying lesion might be present. MRI was carefully performed again, targeted to the L5 vertebral level. Imaging revealed the presence of an extradural cyst located along the left L5 nerve root (Fig. 2). Cyst resection was performed successfully and histopathological examination confirmed the cyst as a perineural cyst.Figure 1.: A, T2-weighted axial MRI at the L4–5 intervertebral disc level. B, Area targeted by the first MRI.Figure 2.: A, T1-weighted axial MRI demonstrating a perineural cyst at the L5 vertebral level. B, T2-weighted axial MRI at the same level. C, Area targeted by the second MRI.Perineural cysts occur most frequently at the sacral level. Sacral perineural cyst, so-called Tarlov cyst, was first described by Tarlov in 1938.1 Langdown et al. reported Tarlov cysts as a relatively common finding on lumbosacral MRI with a prevalence of 1%–2%, and only 13% of cysts were directly responsible for symptoms.2 Perineural cysts may be a rare cause, but should be considered in the differential diagnosis of radiculopathy. Mayumi Takatori, MD Munetaka Hirose, MD Toyoshi Hosokawa, MD Kyoto Prefectural University of Medicine Department of Anesthesiology 465 Kajiicho, Kamigyo-ku Kyoto 602-8566, Japan [email protected]

Clinical Presentation Of Lumbar Disc Herniation: We Must Keep Also Limbus Fracture In Mind As A Cause

A 49-year-old woman presented to Neurosurgery Clinic with a 4-month history of low-back pain radiating to her right leg. Patient's previous medical history was insignificant. There was no history of trauma. Neurological examination revealed a hypoactive Achilles reflex and a positive straight leg-raising test on the right side. Lumbosacral magnetic resonance imaging revealed that the L5-S1 intervertebral disc was herniated into the right L5-S1 foramen. The signal characteristics and the appearance of the lesion were atypical for a herniated disc. Computed tomography scanning showed a posterolateral rim fracture of the L5 inferior vertebral end-plate. The patient underwent surgery that involved wide L5 hemilaminectomy, removal of the fractured limbus, and L5-S1 discectomy. Limbus fractures are less frequent in adults, and they tend to be misdiagnosed. Plain radiography and MRI are often inconclusive and CT is essential for the true diagnosis. Our case is a good example of Type III.

CLINICAL PREDICTORS FOR OUTCOME OF TREATMENT OF LUMBAR HERNIATED NUCLEUS PALPOSUS

Herniated nucleus palposus is a common and important cause of low back pain. Despite over 90% of the patients responding to conservative treatment, some patients still need operation. This study aimed to analyze the clinical predictors for the outcome of conservative treatment in herniated nucleus palposus. Two hundred and fifty-one patients who were diagnosed as lumbar herniated nucleus palposus and admitted to Prince of Songkla University during the period of 1995–2000 were included in the study. Patients who had absolute indications for surgery or had previous back surgery were excluded. Data were collected on demographic characteristics (age, sex, occupation, level of study, marital status), patient symptoms (including duration, characteristic and severity of pain) and result of physical examination (including result of straight leg raising test (SLRT), cross SLRT, motor power, sensory deficit and reflex). The mean age of the patients was 38 years and the mean duration of pain was 4.1 months. Eighty percent of the patients had positive SLRT and abnormal neurological function was found in 73%. One hundred and eighty-six patients underwent surgery owing to failure of conservative treatment. From multivariate logistic analysis, five independent factors affecting failure of conservative treatment of herniated nucleus palposus were pain intensity, duration of symptoms, positive cross SLRT, grade of muscle power and number of dermatome deficit. When constructing the parameters into a scoring system, we found that if the patient had a score less than 45, 80% of them respond to conservative treatment, in contrast to those who scored more than 65, the probability of conservative failure was 80%. This study implies that clinical predictors can be used for determining probability of conservative failure in herniated nucleus palposus.

Racial differences in the use of lumbar spine radiographs: results from the Veterans Health Study.

We analyzed data from the Veterans Health Study, a longitudinal study of male patients receiving VA ambulatory care. To determine whether clinical differences and/or race account for disparities between white and nonwhite patients in the use of lumbar spine radiographs. Four hundred one patients with low back pain (LBP) receiving ambulatory care services in four VA outpatient clinics in the greater Boston area were followed for 12 months. Participants were mailed the Medical Outcome Study Short Form Health Survey (SF-36) and had scheduled interviews that included the completion of a low back questionnaire, a comorbidity index, and a straight leg raising (SLR) test. Using self-reported racial data, patients were grouped as whites (315 patients) and nonwhites (among whom 22 were black, 4 nonwhite Hispanics, and 1 other race). Nonwhite patients had lumbar spine films more often (13 of 27, 48%) than white patients (87 of 315, 27%)(P = 0.02). Nonwhite patients had higher pain intensity scores than white patients (63 +/- 21 vs. 48 +/- 21, P < 0.01) and were more likely to have radiating leg pain (20 of 27, 76%; compared with 171 of 315, 55%; P = 0.01) than white patients. Nonwhite patients had worse physical functioning (P = 0.01), general health perception (P = 0.05), social functioning (P = 0.02), and role limitations because of emotional problems (P < 0.01). At higher LBP intensity level, nonwhite patients received more lumbar spine films (20 of 27, 74%) than did white patients (155 of 315, 50%)(P < 0.01). Among patients with positive SLR test, nonwhite patients also had lumbar spine films more often (5 of 22, 23%) than white patients (29 of 315, 11%) (P < 0.01). However, after adjusting for multiple clinical characteristics, race was no longer found to be an independent predictor of lumbar spine radiograph use. A positive SLR test remained to be associated with higher radiograph use, whereas better mental health status was associated with lower radiograph use. There was greater use of lumbar spine radiographs by nonwhite patients compared with white patients. This remained true when patients were subcategorized by severity of LBP or SLR test. However, race had no influence when multiple clinical characteristics of the patients were controlled for simultaneously. This study demonstrates the importance of careful and comprehensive case-mix adjustment when assessing apparent differences in the use of medical services.

Factors predicting radical treatment after in-hospital conservative management of disk-related sciatica

Objective. To determine predictive factors for radical treatment (nucleolysis or surgery) after in-hospital conservative management of low back pain with sciatica (LBPS). Patients and methods. A standardized form was used to collect data on 134 patients admitted for conservative treatment of LBPS. Subsequent radical procedures were recorded 11 to 24 months after discharge. Results. Forty-seven patients required radical treatment after discharge. Significant risk factors for radical treatment in the univariate analysis were taller stature, use of a lumbar support, more preadmission epidural injections, a positive straight leg-raising test, and a disk herniation diameter of at least 50% of the spinal canal diameter. Protective factors were onset within the month preceding admission and normal range of motion of the lumbar spine. In the multivariate analysis, symptom duration longer than one month, use of a lumbar support prior to admission, and a positive straight leg-raising test were associated with radical treatment. A positive straight leg-raising test was the only significant clinical risk factor in the subset of patients investigated by computed tomography (CT). When CT findings were added to the model, only size of the herniation was significant. Conclusion. Sixty-five percent of patients admitted for conservative treatment of LBPS do not receive radical treatment during a mean follow-up of 18 months. Several factors are associated with the likelihood of radical treatment.

Clinical Appearance of Contained and Noncontained Lumbar Disc Herniation

In a prospective and consecutive study, we evaluated the incidence of common symptoms and neurologic disturbances in 200 patients operated on because of lumbar disc herniation by using a computer-coded protocol with pre- and perioperative registration. The preoperative occurrence of pain at rest, at night, and on coughing was registered. Use of analgesics and walking ability were registered as category data. At examination, a straight-leg-raising (SLR) test was graded in four categories, and results from neurologic findings were collected. At surgery, disc herniation was classified as extruded/sequestered herniation, prolapse, or focal protrusion. There were no significant differences concerning pain at rest or at night related to type of herniation. Pain on coughing was more common in extruded/sequestered herniations. Use of analgesics as well as severe reduction of walking capacity were significantly more common in patients with extrusion/sequestration. The highly restricted SLR test, as well as the crossed positive SLR test, were also significantly more common in patients with extruded/sequestered herniation, and this was also true for the incidence of relevant reflex/extensor hallucis longus (EHL) and sensory disturbance. In conclusion, the clinical appearance of lumbar disc herniation was most "aggressive" in extruded and sequestered disc herniation. The symptoms and signs in disc protrusion were less severe, whereas patients with prolapse had an "intermediate" appearance concerning symptoms and signs. The differences in incidence of common signs in noncontained versus contained herniation were statistically significant; these differences may be of clinical interest for patient selection and information as well as in pathophysiologic considerations.

Influence of age on symptoms and signs in lumbar disc herniation.

In a prospective and consecutive study we evaluated the prevalence of pain-related symptoms, the results of the straight leg raising (SLR) test and neurological disturbances by age group in a total of 150 patients operated on due to lumbar disc herniation. On admission, all patients were interviewed, and pain at rest, at night and on coughing was recorded. Walking capacity was recorded under four categories: > 5 km, 1-5 km, 0.5-1 km and < 0.5 km. Results of the SLR test were also registered as category data: positive 0-30 degrees, positive 30-60 degrees, positive > 60 degrees or negative. Findings from examination of tendon reflexes and power of the extensor hallucis longus (EHL) muscle were registered, as were sensory disturbances. The above mentioned parameters were analysed separately for five different age groups: 20-29 years, 30-39 years, 40-49 years, 50-59 years and above 60 years of age. There was an age-related change in the prevalence of certain parameters. Highly restricted positive SLR test results and pain on coughing was most commonly found in the youngest patient group. With increasing age there was a decreasing prevalence of highly restricted positive SLR test results, while the prevalence of severe reduction of walking capacity increased. In short, the youngest patient group showed the most obvious clinical picture of disc herniation and, with increasing age, the clinical picture gradually changed towards the picture associated with spinal stenosis.

Syndrome of intradiscal lumbar herniation clinical presentation and management

A syndrome of intradiscal lumbar herniation not associated with nerve root compression is described. The patients have a history similar to that seen in classic disk herniation, except the paresthesias and pain are “referred” roughly in a dermatomal distribution. On examination, limitation of range of motion of the back secondary to muscle spasm is noted; however, a positive straight leg-raising test result is not. Objective neurological findings are much less obvious than with radiculopathy. These patients may have “weakness” from lack of effort on their part during the examination. There is noted asymmetry in appropriate reflexes and also in the sensory examination. Standard imaging examinations are equivocal. If explored surgically, the findings are relatively unimpressive. These patients, if correctly identified, may be candidates for percutaneous nuclectomy.

Vertebral Osteomyelitis Due to Pseudomonas in the Occasional Heroin User

VERTEBRAL osteomyelitis is a recognized complication of heroin addiction.1,2The following two cases of vertebral osteomyelitis resulting fromPseudomonasinfection are presented to emphasize that this entity can occur in patients who have used heroin only occasionally. Report of Cases Case 1.— A 24-year-old man had low back pain of one month's duration. He admitted having twice used heroin intravenously, most recently five months before admission. Physical examination gave normal results except for pain localized in the L3-4 area of the spine and a positive straightleg-raising test. The patient had occasional evening temperature elevations between 37.8 and 38.3 C (100 and 101 F). The erythrocyte sedimentation rate was persistently elevated above 30 mm/hr; on the other hand, he had no leukocytosis, and six blood cultures were negative. Initial lumbosacral spine roentgenograms were normal. Two weeks later, however, narrowing of the L3-4 intervertebral disk space was noted. Cultures of tissue