Pseudoradicular Pain Research Articles

The Sacroiliac Joint as a Cause of Pain - Review of the Sacroiliac Joint Morphology and Models for Pain Genesis.

In recent years, the sacroiliac joint has become increasingly important as a generator of low back pain with and without pseudo-radicular pain in the legs. Up to 27% of reported back pain is generated by disorders in the sacroiliac joint. This review is based on a selective literature search of the sacroiliac joint (SIJ) as a possible pain generator. It also considers the anatomical structures and innervation of the sacroiliac joint. The SIJ is a complex joint in the region of the posterior pelvis and is formed by the sacrum and the ilium bones. The SIJ is very limited in movement in all three planes. Joint stability is ensured by the shape and especially by strong interosseous and extraosseous ligaments. Different anatomical variants of the sacroiliac joint, such as additional extra-articular secondary joints or ossification centres, can be regularly observed in CT scans. There is still controversy in the literature regarding innervation. However, there is agreement on dorsal innervation of the sacroiliac joint from lateral branches of the dorsal rami of the spinal nerves S I-S III with proportions of L III and L IV as well S IV. Nerve fibres and mechanoreceptors can also be detected in the surrounding ligaments. A closer look at the anatomy and innervation of the SIJ shows that the SIJ is more than a simple joint. The complex interaction of the SIJ with its surrounding structures opens the possibility that pain arises from this area. The SIJ and its surrounding structures should be included in the diagnosis and treatment of back and leg pain. Published literature include a number of plausible models for the sacroiliac joint as pain generator. The knowledge of the special anatomy, the complex innervation as well as the special and sometimes very individual functionality of this joint, enhance our understanding of associated pathologies and complaints.

The dimensions of "failed back surgery syndrome": what is behind a label?

The term failed back surgery syndrome (FBSS) has been criticized for being too unspecific and several studies have shown that a variety of conditions may underlie this label. The aims of the present study were to describe the specific symptoms and to investigate the primary and secondary underlying causes of FBSS in a contemporary series of patients who had lumbar spinal surgery before. We used a multilevel approach along three different axes defining symptomatic, morphological, and functional pathology dimensions. Within the study period of 3years, a total of 145 patients (74 f, 71 m, mean age 51a, range 32-82a) with the external diagnosis of FBSS were included. Disk surgery up to 4 times and surgery for spinal stenosis up to 3 times were the commonest index operations. Most often, the patients complained of low back pain (n = 126), pseudoradicular pain (n = 54), and neuropathic pain (n = 44). Imaging revealed osteochondrosis (n = 61), spondylarthrosis (n = 48), and spinal misalignment (n = 32) as the most frequent morphological changes. The majority of patients were assigned at least to two different symptomatic subcategories and morphological subcategories, respectively. According to these findings, one or more functional pathologies were assigned in 131/145 patients that subsequently enabled a specific treatment strategy. FBSS has become rather a vague and imprecisely used generic term. We suggest that it should be avoided in the future both with regard to its partially stigmatizing connotation and its inherent hindering to provide individualized medicine.

Hereditary Neuropathy with Liability to Pressure Palsies Masked by Previous Gunshots and Tuberculosis

Objectives. Although hereditary neuropathy with liability to pressure palsies (HNPP) presents with a distinct phenotype on history, clinical exam, and nerve conduction studies, it may be masked if diagnostic work-up suggests other causes. Case Report. In a 37-year-old male with pseudoradicular lumbar pain, neurological exam revealed sore neck muscles, peripheral facial nerve palsy, right anacusis and left hypoacusis, hemihypesthesia of the right face, mild distal quadriparesis, diffuse wasting, and generally reduced tendon reflexes. He had a history of skull fracture due to a gunshot behind the right ear and tuberculosis for which he had received adequate treatment for 3 years; MRI revealed a disc prolapse at C6/7 and Th11/12. Nerve conduction studies were indicative of demyelinating polyneuropathy with conduction blocks. Despite elevated antinuclear antibodies and elevated CSF-protein, HNPP was diagnosed genetically after having excluded vasculitis, CIDP, radiculopathy, and the side effects of antituberculous treatment. Conclusions. HNPP may manifest with mild, painless, distal quadriparesis. The diagnosis of HNPP may be blurred by a history of tuberculosis, tuberculostatic treatment, hepatitis, and the presence of elevated CSF-protein.

High noon back pain- severe pseudoradicular pain as a lead symptom of superficial siderosis: a case report.

A superficial siderosis of the central nervous system following a traumatic cervical nerve root avulsion usually leads to gait difficulties and hearing loss, whereas back pain is described only rarely. Here we report on the first case with circadian occurrence of severe back pain as the only symptom of a superficial siderosis. We present a case with the most severe pseudoradicular lumbosacral pain occurring daily at noon for the past 5 weeks. The 48-year-old male white patient did not complain of pain in the morning. A traumatic root avulsion 26 years earlier led to a brachial plexus palsy and Horner's syndrome in this patient. Superficial hemosiderosis in cranial MRI and examination of the cerebrospinal fluid revealing massive red blood cells as well as xanthochromia and elevated protein levels (742 mg/l) led to the diagnosis of a superficial siderosis. A pseudomeningocele caused by a cervical nerve root avulsion is described as a rare reason for superficial siderosis. Surgery on a pseudomeningocele, diagnosed by MRI, led to an immediate disappearance of complaints in our case. Regular neurological investigation and possibly repeated lumbar puncture to exclude superficial siderosis should be considered in cases with severe back pain and a history of traumatic root avulsion. Modern susceptibility weighted MR imaging (SWI) techniques, sensible to the detection of superficial hemosiderosis, might be helpful in the making of a diagnosis.

ОШИБКИ ДИАГНОСТИКИ И ЛЕЧЕНИЯ ВЕРТЕБРОГЕННОГО ШЕЙНОГО КОРЕШКОВОГО КОМПРЕССИОННОГО СИНДРОМА И ПСЕВДОРАДИКУЛЯРНЫХ БРАХИАЛГИЙ

Objective. To analyze adverse outcomes of surgical treatment of radicular compression syndrome and to present an algorithm for diagnosis and differential treatment of radicular and pseudoraducular brachialgias. Material and Methods. The catamneses of 60 patients hospitalized for adverse outcome of previous surgery for cervical radicular compression syndrome were studied. Analysis of errors and developed algorithm for diagnosis and differential treatment of upper limb pain syndromes facilitated the prospective study of 350 patients with pseudoradicular brachialgia caused by pathological impulses from the affected intervertebral discs and facet joints. Results. Stable regression of pseudoradicular arm pain was achieved in 94 % of patients. Disc puncture reproduction of patient’s specific arm pain and its elimination by means of chemical denervation confirmed the dependence of this pain mainly on degenerative disc disease in 33.8 % of cases, on spondylarthrosis in 6.7 %, and equally on degenerative disc disease and spondylarthrosis in 59.5 %. Conclusion. The developed algorithm for diagnosis and differentiated treatment of upper limb pain syndromes depending on the combination of different pathomorphological substrates and syndromes can improve the results of treatment in patients with brachialgia and achieve stable regression of pseudoradicular pain.

Pseudoradicular and radicular low-back pain – A disease continuum rather than different entities? Answers from quantitative sensory testing

To assess whether pseudoradicular low-back pain may be associated with subclinical sensory deficits in the distal extremity, we applied the quantitative sensory testing protocol of the German Research Network on Neuropathic Pain (DFNS) in 15 patients with pseudoradicular pain distribution. Sixteen age- and gender-matched healthy control subjects as well as 12 patients with radicular pain syndromes (L4-S1) were studied with the same protocol. Radicular pain was diagnosed using clinical criteria (pain radiation beyond the knee, motor-, sensory-, or reflex deficits, positive Laségue’s test). Z-score QST profiles revealed a selective loss of vibration detection, detection of v. Frey hair contact, and cold detection in the affected dermatomes in the radicular pain group. The contralateral dermatome was also affected, but to a lesser degree. In patients with pseudoradicular pain, the sensory profile was similar, but sensory loss was less pronounced than in the radicular pain patients. There was no significant difference between the two patient groups. Vibration detection was the most sensitive parameter with 73% abnormal values in radicular and 47% in pseudoradicular cases. These data verified the sensitivity of QST to detect sensory loss in radicular compression syndromes, and support a neuropathic component in low-back pain with radiculopathy. In contrast to some central pain syndromes this sensory loss involved predominantly large fiber functions. The subclinical sensory loss in pseudoradicular cases suggests that these patients may also have a neuropathic component of their chronic pain. The spatial incongruence of pain and sensory loss in pseudoradicular pain, however, may also indicate that the two are not causally related.

Diagnostic Differences Between General Practitioners and Orthopaedic Surgeons in Low Back Pain Patients

Background. There is a growing consensus on low back pain treatment. However, whether this extends to diagnostic labelling is still largely unknown. The aim of this report was to compare the diagnostic assessment of low back pain patients between general practitioners trained in manual therapy and orthopaedic surgeons.Methods. Population-based randomized controlled trial in which 160 patients with acute or sub-acute low back pain were assessed and treated by general practitioners or orthopaedic surgeons. Information on diagnoses and use of diagnostic imaging was obtained from medical records and physician questionnaires covering the ten-week treatment period. The Quebec Task Force classification and free text analysis were used to group diagnostic labels.Results: At baseline there were no significant differences in medical history, findings at physical examination and distribution of the Quebec Task Force diagnostic classification between the patient groups, indicating that they were similar. However, there were significant differences in physicians’ use of diagnostic labels for local pain and their characterisation of radiating pain. General practitioners used more terms from manual medicine and reported more pseudoradicular pain than orthopaedic surgeons, who used non-specific pain labels, reported more true radicular pain and used more x-ray examinations. Differences were found at all times from first visit to ten week follow-up.Conclusions: There were significant differences in diagnostic assessment and use of diagnostic radiology between general practitioners and orthopaedic surgeons.

Pain as heralding symptom in multiple sclerosis

It is becoming recognised that neuropathic pain is among the major burdens of patients affected by multiple sclerosis (MS). Neuropathic pain may be an early symptom of the disease. Well known presentations are symptomatic trigeminal neuralgia and also pseudo-radicular pain due to lesions of the dorsal entry zone. Here we report two patients with visceral pain and three patients with pseudo-radicular pain due to spinothalamic lesion (central pain) caused by MS. The diagnosis was hampered and delayed by the absence of objective signs. In four patients the only abnormal clinical finding was spinothalamic hypoaesthesia. Pain may be one of the heralding symptoms of MS. In the present series it was severe, chronic and poorly responsive to treatment. A sensory examination is mandatory in all cases of complex pain syndromes of unidentified nature.

Low Back Pain Secondary To Unilateral Facet Joint Hypoplasia In The Lumbosacral Junction

Introduction: The authors intention was to report the clinical, radiological, intraand postoperative findings of a patient with low back pain and pseudoradicular pain radiation to the left leg. As reason, a considerable hypoplasia of the left inferior facet joint of L5 and dysplastic cranial facet joint of S1 was detected. To the authors knowledge no case of facet joint dysplasia with ipsilateral pain has been reported so far. Methods: Different forms of dysplasia or false orientation of the facet joints in the lumbosacral joints are described to cause low back pain. One case of recurrent low back pain with pseudoradicular radiation is reported. Medical and radiological reports and related literature were reviewed. Results and Discussion: A 44 years old woman complained about recurrent low back pain consisting for 2 years. 4 weeks before admission to our clinic, a pseudoradicular leg pain on the left side occurred. Roentgenographic findings showed an aplasia of the left facet joint of L5/S1, MR tomography revealed disc degeneration in the lumbo-sacral junction. Computed tomography including 3D reconstruction showed a considerable hypoplasia of the left inferior articular facet L5. A possible reason for leftsided pseudoradicular leg pain, a dysplastic left sacral articular process was detected forming a sclerotic degenerated pseudoarticulation with the left hemilamina of L5. There was no pain relief after conservative treatment. Diagnostic investigations for instability including a probative chest tube and a facet infiltration of the facet joint on the left side were followed by complete pain relief. A spinal fusion in unilateral transforaminal posterior interbody fusion technique (PLIF) from the left side led to complete remission of back pain and pseudoradicular radiation. Conclusions: Hypoplasia of the facet joint in the lumbosacral junction is extremely rare to cause back pain. If conservative treatment does not result in pain relief, spinal fusion may be indicated.

Percutaneous discography: comparison of low-dose CT, fluoroscopy and MRI in the diagnosis of lumbar disc disruption

To compare the diagnostic accuracy of low-dose computed tomography (CT), magnetic resonance imaging (MRI) and fluoroscopy in percutaneous discography in patients scheduled for lumbar spondylodesis. Within a prospective pilot study, 18 disc segments of 11 patients with radicular or pseudoradicular pain prior to anteroposterior spondylodesis were evaluated. After injection of a mixture of non-ionic iodine-containing contrast agent and gadolinium-based contrast medium into the disc spaces, all patients underwent conventional fluoroscopy, as well as low-dose CT and MRI. The occurrence of memory pain during contrast injection was recorded. CT, MRI and fluoroscopic images were analyzed independently by two readers blinded to the clinical findings. There was 100% agreement between CT and MRI discography in the detection, localization and grading of degenerative changes. In contrast, conventional fluoroscopy identified only 9 of the 12 abnormal segments. Memory pain following puncture was identified in 3 of the 12 affected segments. Low-dose CT and MRI discography have a similar accuracy in the assessment of disc disruption and they are superior to fluoroscopic discography.

CT-guided percutaneous laser disc decompression with Ceralas D, a diode laser with 980-nm wavelength and 200-microm fiber optics.

The aim of this study was to evaluate the compact, portable Ceralas-D diode laser (CeramOptec; 980 + 30 nm wavelength, 200-microm optical fiber) concerning clinical usefulness, handling, and clinical results in the CT-guided treatment of herniated lumbar discs. The positioning of the canula in intradiscal space, the placement of the laser fiber into the disc through the lying canula, and the vaporization itself were carried out under CT-guidance. Due to the thin fiber optic, it was possible to use a thin 23-gauge canula. The laser procedure was performed in 0.1- to 1-s shots with 1-s pulse pause and 4-W power output. A total of 1650-2300 J was applied on each percutaneous laser disc decompression (PLDD). Results in 26 patients were established with a visual-analogue scale (VAS). On the follow-up examinations, 46% of the patients were absolutely pain free ( > 85 % VAS) and fully active in everyday life after 4 postoperative weeks. Thirty-one percent of patients were relieved of the leg pain but had occasional back pain without sensorimotor impairment. Fifteen percent sensed a slight alleviation ( > 50% VAS) of the radiate pain. Eight percent did not experience radicular or pseudo-radicular pain alleviation (< 25% VAS). Cerales-D proves to be an efficient tool for CT-guided PLDD on non-sequestered herniated lumbar discs.

A paramedian tangential approach to lumbosacral extraforaminal disc herniations.

Extraforaminal disc herniations today are operated on via the so-called lateral approach. Clinical experience has shown that in contrast to levels L2/3-L4/5, this approach may become extremely difficult at the L5-S1 level. According to new microanatomic studies, the previous lateral approaches at this level often do not allow access to the neuroforamen without partial or total destruction of the L5-S1 facet joint. Postoperatively, this may lead to joint irritation with consecutive low back and pseudoradicular pain. To preserve the facet joint, a new approach was developed based on an anatomic study. The approach was first considered with the help of bone specimens including ilium, vertebra 5, and sacrum. Thereafter, lumbar maceration specimens were prepared leaving ligaments, intervertebral discs, and joints intact. From these specimens, bony and ligamentous landmarks were deduced. Finally, the approach was tested on seven cadavers. Subsequently, the approach was performed on 13 patients and the intraoperative findings, the clinical feasibility, and the postoperative results were analyzed. After a transverse skin incision above the dorsal curvature of the ilium, the paravertebral muscles are dissected from the ilium medially toward the spinous process. Lateral from the apophyseal joint, a canal is drilled through the spongiosa of the sacrum. Primarily, a thin layer of inner cortex is spared to protect the content of the neuroforamen. Subsequently, it can easily be removed with the dissector to enter the extraforaminal space. In the depth of the drilled canal, the nerve root is found, because it is fixed at the sacrum near the disc space by the anterior lumbosacral ligaments. Riding on the nerve root, the intertransverse ligament and muscle can be removed with the punch. It is then possible to see the neuroforamen and extraforaminal space in front of the joint. Free fragments and contained discs can then easily be found and removed. Using this new approach, the L5-S1 joint remains intact. Space for instrumental manipulations is created in areas not essential for joint function. For this procedure, newly defined anatomic landmarks, such as the ileolumbar ligament, upper edge of the sacrum, lateral rim of the apophyseal joint, and para-articular notch, guide the operative route. In accordance with the preliminary anatomic studies, this approach was successfully used in 13 patients, and we think that it is a promising alternative that helps to preserve joint function and dorsal root ganglion integrity.

Low back pain due to extramedullary hemopoiesis

Two cases of extramedullary hemopoiesis in the lower spinal column are reported. One of them was due to thalassemia major and the other to thalassemia intermedia. CT and MRI studies showed paraspinal and presacral masses respectively which caused nerve root compression. It is concluded that the differential diagnosis of low back pain and radicular or pseudoradicular pain should include extramedullary hemopoiesis.

Surgical results of 300 patients of lumbar spine diseases with special concern to "pseudoradicular pain".

The results of the microsurgical treatment of 300 patients with painful lumbar spinal diseases were reported. Radical removal of the disc material, preservation of the epidural fat tissue around the lumbar nerve roots, and meticulous hemostasis produced good results. Yet, even with this technique, a pseudoradicular or referred pain still developed after surgery, despite of the disappearance of a radicular pain or radicular signs. Pseudoradicular pain is characterized by: 1) Lasegue sign only after raising the straightened leg more than 40 degrees; 2) no radicular signs; 3) marked pains localized in the area innervated by the dorsal ramus which is involved in a pathological process; and 4) no pain in the popliteal fossa.10) Our operative results revealed that this uncomfortable pain developed most frequently after operative procedures involving facets and lateral recesses, such as in facetectomy or foraminotomy for superior facet syndrome (80% postoperatively) and for cases of lumbar herniated disc (63% postoperatively). The pain could be elicited by stimulation or irritation of the dorsal rami of the lumbar spinal nerves during surgery involving the articular facets. That was why pseudoradicular pain frequently developed after treatment of superior facet syndrome based on hypertrophied articular process or lumbar herniated discs.

The Role of Laminectomy, Facet Rhizotomy, and Epidural Steroids

A retrospective review of the treatment of chronic back and extremity pain is presented. Laminectomy is most effective for pain secondary to direct compression of the neural elements. Treatment of pseudoradicular pain requires identification of the source of pain input. Facet rhizotomy is specific for pain arising from the posterior primary rami. Pain input from the recurrent sinuvertebral nerve requires epidural injection.