Relief Of Radicular Pain Research Articles

Minimally invasive posterior cervical microforaminotomy in the lower cervical spine and C-T junction assisted by O-arm-based navigation

Navigated posterior cervical microforaminotomy (PCM) is a promising minimally invasive technique for treating radiculopathy caused by lateral disc herniations and foraminal stenosis. Between December 2009 and October 2010, 14 patients with unilateral foraminal disc herniations or foraminal stenosis at the C6-7 or C7-T1 level underwent PCM assisted by O-arm navigation using the METRx tubular retractor. The main symptoms were radicular arm pain with no significant neck pain. Successful relief of radicular pain was achieved in all 14 patients. Two of the patients were lost during follow-up, and three had to undergo further decompression due to remnant foraminal stenosis being discovered on intraoperative O-arm images. There were no cases of instability or recurrence, and the only complication observed was a dural tear in one patient, which was adequately treated with fibrin glue and bed rest. The duration of symptoms was 4.5 months on average. The mean operation time was 136 minutes, with the additional time required for the image guided surgery assisted by O-arm-based navigation being approximately 28 minutes on average. There were no other complications during the surgical procedure or in the immediate postoperative period. Posterior cervical microforaminotomy assisted by O-arm-based navigation is a safe, effective and minimally invasive procedure for the treatment of lateral disc herniations and foraminal stenosis of the lower cervical spine and C-T junction, offering the possibility of an accurate decompression with a reduced risk of segmental instability.

Resultados clínicos e radiológicos en serie de artrodesis cervical anterior con caja de fusión intersomática y placa

OBJETIVOS: Analizar los resultados clínicos e radiológicos de una serie de pacientes sometidos a artrodesis cervical anterior con caja de fusión intersomática (CAGE) y placa. MÉTODOS: Análisis retrospectivo de serie de pacientes sometidos a artrodesis cervical anterior con caja de fusión intersomática y placa entre los años 2004 y 2009. Revisión de fichas clínicas y radiografías, registro de edad, sexo, diagnósticos, nivel operado, complicaciones, evolución clínica y radiológica. Técnica quirúrgica de Smith-Robinson. Las cajas de fusión intersomática fueron llenadas con sustitutos de huesos. Deambulación 12 horas después de la cirugía, alta a las 48 horas, collar cervical intermitente por 2 semanas. Evaluación clínica mediante criterios de Odom. Seguimiento 17 a 78 meses. RESULTADOS: Diagnósticos: Hernia del núcleo pulposo (HNP) cervical, 44 (71%), mielopatía, 11 (17,7%), fracturas, 7 (11,3%). Nivel 1: 44 (71%), Nivel 2: 15 (24,2%), Nivel 3: (4,8%). El nivel C5-C6 incluyó 92% de los casos. Alivio del dolor radicular: 60 (97%). Recuperación del déficit neurológico: 59 (95,2%). Alivio de la mielopatía: 8/11 pacientes (73%). Alivio del dolor cervical: 56 (90%). Resultados clínicos: 91,9% excelentes y buenos. Complicaciones (12,9%): 4 disfagias transitorias (6,5%), 1 disfagia permanente (1,6%), 2 disfonías transitorias (3,3%), 1 subcidencia con aflojamiento del implante y fractura asintomática de placa (1,6%). No hubo pseudoartrosis. CONCLUSIONES: Esta serie presenta buenos resultados clínicos, com alivio del dolor y recuperación neurológica comparables con los hallazgos en la literatura. El uso de la caja de fusión intersomática evita complicaciones de la zona dadora y, cuando es asociado a placa cervical anterior permite fijación intersomática inmediata, dando soporte estructural adecuado, con buenos resultados y sin complicaciones a largo plazo.

Posterior Decompression of Far-Out Foraminal Stenosis Caused by a Lumbosacral Transitional Vertebra -Case Report-

A 29-year-old man presented with a rare case of far-out foraminal stenosis with radiculopathy caused by osteophyte formation secondary to an anomalous articulation between the transverse process and the sacral ala. Diagnosis of unilateral far-out foraminal entrapment of the L5 spinal nerve below a transitional vertebra (TV) depended on selective radiculography and nerve root block. Computed tomography after selective radiculography clearly demonstrated foraminal entrapment of the L5 nerve root via the osteophytes. The patient underwent posterior decompression by resection of the osteophytes using an operating microscope and experienced good relief of radicular pain. This case illustrates the effectiveness and some refinements of posterior decompression for radicular pain caused by far-out foraminal stenosis below a TV and compression of the L5 spinal nerve.

Relief of radicular pain in metastatic disease by vertebroplasty

Two patients with compression fractures from metastases who had pain with radicular symptoms mainly in upright position that resolved when not upright and were treated with vertebroplasty were retrospectively analyzed. Both patients had symptom relief at treated levels until death. These cases show that patients with radicular signs and symptoms from compression fractures secondary to metastases or myeloma, worse in upright position and relieved when recumbent, may benefit from vertebroplasty.

Posterior microlaminoforaminotomy for cervical disc herniation

Background and purposePosterior microlaminoforaminotomy is a surgical treatment option for lateral cervical disc herniation. This approach avoids injury of vital structures lying in front of the cervical spine and preserves mobility of the treated spinal segment. The authors present the outcome of 20 patients operated on using this method. Material and methodsRetrospective analysis was performed on 20 consecutive patients operated on in the years 2005-2009. Posterior microlaminoforaminotomy was used in patients with unilateral cervical radiculopathy resulting from lateral disc herniation. Osteophytes coexisted in 12 cases. The presenting symptoms were: radicular pain (20 patients), paraesthesias (19), neck pain (17), dermatomal sensory loss (11) and motor deficit (9 patients). All operations were performed at a single level (C5/C6 in 8 cases, C6/C7 in 10 cases, C7/Th1 in 2 cases). ResultsThe herniated disc was removed in 19 cases; nerve root decompression was performed in 1 patient. Osteophytes were additionally excised in 4 cases. Significant relief of radicular pain was achieved in all cases early after surgery. Transient improvement with unsatisfactory late outcome was observed in 1 patient. Satisfactory late outcome (according to Odom's criteria) was obtained in 95% (18/19) of patients. Complete or marked improvement of radicular pain was observed in 95% (18/19), neck pain in 94% (16/17), sensory loss in 82% (9/11) and motor deficit in 78% (7/9). There was no case of spinal instability or secondary operation due to recurrence with a mean follow-up period of 22 months. ConclusionsPosterior microlaminoforaminotomy is safe and effective. Coexistence of osteophytes does not limit use of this technique. The risk of herniation recurrence and spinal instability is very low. The minimal invasiveness of this method allows faster return to normal life activities.

Cervical arthroplasty with Discocerv™ “Cervidisc Evolution” surgical procedure and clinical experience 9 years after the first implantation of the first generation

Long time considered as gold standard in the surgical treatment of the cervical disc disease, anterior discectomy and fusion is, however, associated with an important rate of complications and low quality of life levels, especially in young and active populations. As literature emphasized a correlation between fusion (and the resulting suppression of motion) and adjacent segment degeneration, motion-preserving techniques have been imagined; most of them involve cervical disc prostheses that are under clinical and biomechanical evaluation. Various materials and designs are proposed, with the common point that motion axis is located downwards (with regard to the prosthesis), thus allowing not only a physiologicalmotion in a sagittal plane but also some possible mechanical conflicts between unci and the upper vertebra. Uncus resection may solve the conflict, however, with a great risk of postoperative ossification of bone spurs. For a prosthesis whose motion axis is located upwards, motion in frontal plane is physiological, avoiding the aforementioned mechanical conflict and the need for uncus resection. However, the movements in a sagittal plane may be altered, so we studied such a concept of prosthesis from a clinical and biomechanical point of view. The population consisted in 36 patients who underwent cervical arthroplasty with Discocerv™ “Cervidisc Evolution” for cervical degenerative diseases without instability. Among this group, 21 (8 men, 13 women, mean age: 49 ± 9 years) patients reached the 12-month follow-up. The following data were analyzed — (A) clinical: surgery data, complications, return to work, pain (VAS), function (NDI) and overall outcome (Odom’s criteria); (B) radiological: flexion-extension motion, mean centers of rotation, local and C1–C7 lordosis, signs of degeneration or implant migration. Surgery duration was of 65 ± 15 min and the average hospital stay of 4 days. There were one case of per-operative minor (important bleeding) and three cases of postoperative complications (unrelated to the prosthesis). Twelve months after surgery, an important cervical and radicular pain relief was underlined by postoperative values of respectively 22.6 and 20.3 versus 69.1 and 65.3 observed before surgery. Functional disability diminished from 55.4/100 before surgery to 18.7/100 at 1-year follow-up and 83% of patients declared high levels of satisfaction. These findings are in agreement with Odom’s criteria showing 76% of excellent and 24% of good results, 12 months after surgery, and with the good return to work rate (83% of patients resumed their previous activities within 6 months). Radiological analysis showed preserved motion for the treated level (average: 9.2 ± 4°) and adjacent ones at 12 months, with normal centers of rotation in 64% of cases (in all postoperative examinations) and altered but stable in 36% of cases, where motion axis was located more on the superior plate of the prosthesis. A statistically significant difference between pre- and postoperative values of local lordosis showed a restoration of sagittal alignment. Moreover the absence of a significant postoperative evolution as well as the statistically significant differences between long-term post-and preoperative values of C1–C7 lordosis confirmed this progressive realignment. The findings of this ongoing prospective study highlighted encouraging preliminary results suggesting the efficacy of the device in symptoms relief and motion preservation. Nevertheless, they need to be validated by the long-term results, which will clearly show if the device is able to maintain motion while preventing adjacent segment disease.

Sciatic Nerve Release Following Fracture or Reconstructive Surgery of the Acetabulum

Sciatic neuropathy associated with acetabular fractures can result in disabling long-term symptoms. The purpose of this retrospective study was to evaluate the effect of sciatic nerve release on sciatic neuropathy associated with acetabular fractures and reconstructive acetabular surgery. Between 2000 and 2004, ten patients with sciatic neuropathy associated with an acetabular fracture were treated with release of the sciatic nerve from scar tissue and heterotopic bone. Additional surgical procedures included open reduction and internal fixation of the acetabulum (five patients), removal of hardware and total hip arthroplasty (three patients), and removal of hardware alone (one patient). The average age of the patients was forty-three years. All patients were followed with serial examinations and assessments for a minimum of one year (average, twenty-six months). All patients had partial to complete relief of radicular pain, of diminished sensation, and of paresthesias after the nerve release. Four of seven patients with motor loss and two of five patients with a footdrop demonstrated improvement in function after the nerve release. No patient had evidence of worsening on neurologic examination after the release. Sciatic nerve release during reconstructive acetabular surgery can decrease the sensory symptoms of preoperative sciatic neuropathy associated with a previous acetabular fracture. Motor symptoms, however, are less likely to resolve following nerve release.

Preoperative Narcotic Use as a Predictor of Clinical Outcome

Prognostic Study, Level II (Retrospective review of prospectively collected data). To identify an association between preoperative narcotic use and clinical outcome after cervical arthrodesis. Little data exists regarding the influence that chronic preoperative narcotic use has on clinical outcomes after surgery. Cervical arthrodesis is a common procedure that has a predictably high success rate for relief of radicular pain. In addition, the patient population presenting for this procedure has a high propensity for preoperative narcotic use. Charts and prospectively collected questionnaires concerning the use of pain medication from 91 consecutive patients who underwent cervical arthrodesis for relief of radicular pain by a single surgeon at a single institution were reviewed. Group I consisted of 47 patients who took narcotic pain medication for their radicular pain on a daily basis for greater than 6 months before surgery. Group II consisted of 44 patients who were not on narcotics chronically before surgery. Postoperative narcotic use and patient outcome based on the modified Robinson criteria were assessed. Patients were observed for a minimum of 2 years. Of the group I patients, 16 (34%) continued to require chronic narcotic pain medication up to 2 years after surgery whereas only 3 (7%) of the group II patients required narcotic pain medication past 3 months (P = 0.002). Of the group I patients, 24 (51%) had a good or excellent result after surgery and 15 (32%) had a poor result whereas 38 (86%) of the group II patients had a good or excellent result and no patient had a poor result (P < 0.001). Chronic narcotic use before cervical arthrodesis was found to be associated with continued narcotic use after surgery and worse functional outcomes following surgery. While further studies will be necessary to ascertain if this relationship is generalizable to other orthopaedic procedures and to analyze for potential confounding variables, surgeons may want to counsel their patients about the potential for inferior clinical outcomes if narcotics are used before surgery.

Sciatic Nerve Release Following Fracture or Reconstructive Surgery of the Acetabulum

Sciatic neuropathy associated with acetabular fractures can result in disabling long-term symptoms. The purpose of this retrospective study was to evaluate the effect of sciatic nerve release on sciatic neuropathy associated with acetabular fractures and reconstructive acetabular surgery. Between 2000 and 2004, ten patients with sciatic neuropathy associated with an acetabular fracture were treated with release of the sciatic nerve from scar tissue and heterotopic bone. Additional surgical procedures included open reduction and internal fixation of the acetabulum (five patients), removal of hardware and total hip arthroplasty (three patients), and removal of hardware alone (one patient). The average age of the patients was forty-three years. All patients were followed with serial examinations and assessments for a minimum of one year (average, twenty-six months). All patients had partial to complete relief of radicular pain, of diminished sensation, and of paresthesias after the nerve release. Four of seven patients with motor loss and two of five patients with a footdrop demonstrated improvement in function after the nerve release. No patient had evidence of worsening on neurologic examination after the release. Sciatic nerve release during reconstructive acetabular surgery can decrease the sensory symptoms of preoperative sciatic neuropathy associated with a previous acetabular fracture. Motor symptoms, however, are less likely to resolve following nerve release.

Intradiscal corticosteroid injections in spondylotic cervical radiculopathy

The purpose of this study was to evaluate treatment outcomes with intradiscal injection of corticosteroids (IDIC) in cervical spondylotic radiculopathy. Twenty consecutive patients were treated with intradiscal injection of 25 mg of acetate of prednisolone under fluoroscopic control. All patients had previously received a nonsurgical treatment for at least 3 months without success. Outcomes were assessed 1, 3 and 6 months after IDIC. Radicular pain reduction as scored on a visual analogue scale (VAS 100-mm length) was statistically significant at 1 month (19.0+/-28.0 mm; p=0.008), 3 months (25.2+/-27.5 mm; p=0.002), and 6 months (24.6+/-28.4 mm; p=0.001). In all, 40% of treated patients described at least 50% pain improvement 6 months after treatment. Four patients had complete relief of radicular pain. In conclusion, IDIC should be an alternative in the nonsurgical management of cervical spondylotic radiculopathy.

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

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

Lumbar spine injection and interventional procedures in the management of low back pain.

Lumbar spine injections play a role in the evaluation and treatment of low back pain and lumbar radiculopathy. These injection procedures have been demonstrated to be effective in determining the pain generator for low back pain. There is still debate as to the long-term pain relief from epidural and intra-articular facet joint injections, and no controlled studies have examined the long-term effects of SI joint injections. Additional investigation is certainly warranted to evaluate further the long-term benefits and determine with patients would benefit the most from these injections. Current evidence validates that these injections provide temporary relief of low back and radicular leg pain up to several months, if not longer. This duration of pain relief creates an opportunity to maximize rehabilitation efforts while symptoms are minimal.

LESS INVASIVE PROCEDURES IN SPINE SURGERY☆

The financial pressures on the health-care system and the push to reduce hospital stays have provided a strong impetus toward minimally invasive procedures in all surgical specialties. These procedures frequently are associated with decreased perioperative morbidity, decreased duration of hospital stay, and reduced costs. Minimally invasive procedures are often popularized in the media or are advertised, and surgeons sometimes feel pressure to use new procedures to maintain a competitive practice. However, these types of procedures frequently require highly specialized equipment and training, and their outcome in the context of more traditional approaches needs to be carefully considered. Additionally, these procedures are often associated with unique and sometimes catastrophic complications. Lumbar microdiscectomy, video-assisted thoracoscopic surgery, and kyphoplasty represent relatively new minimally invasive techniques in spine surgery. We will discuss the current status of these procedures and the evidence supporting their increasing use in the management of spine patients. Patient selection remains a key to success for the newer minimally invasive techniques. Lumbar disc excision is the most commonly performed operation on the spine. When patients are carefully selected and the procedure is performed well, it is a highly effective surgical procedure. Multiple authors have reported minimal success rates of 85% with relief of radicular pain when discectomy is performed with traditional methods. Approximately 5% of patients have recurrent herniation of a disc, and 10% to 15% report residual low-back pain 1-7. The traditional indications for surgery for lumbar radiculopathy due to a herniated disc are persistent or recurrent sciatic pain, gross motor weakness, bowel and bladder dysfunction, and abnormalities on neurologic examination and/or nerve conduction studies. Pain, the most common indication for intervention, has evolved to a relative indication on the basis of the degree of incapacity experienced by the patient. The generally accepted current criteria for surgery …

The translaminar approach to canalicular and cranio-dorsolateral lumbar disc herniations.

The interlaminar approach is the standard procedure for most disc herniations in lumbar spine surgery. However, in cranially extruded disc herniations including canalicular herniations, partial or complete facetectomy is necessary with increased risk of postoperative spinal instability. We present the translaminar technique which allows a more direct and less destructive operative approach. 30 patients using the translaminar fenestration were analysed by a postoperative follow-up of 6 weeks and one year. The mean-age was 57.2 years. For resection of the disc herniation, a small round or oval fenestration (6-8 mm) in the hemilamina, craniomedially to the facet joint, was performed. No patient received a partial or total facetectomy. The majority of affected discs were at the L4-L5 level (53%). An extruded fragment was found in 28 patients (93%). In 5 patients bleeding from epidural veins complicated the intra-operative course. In 50% the nerve root was visually exposed. 15 patients (50%) had an intervertebral discectomy additional to the fragment excision. One patient was re-operated on after 10 days because of persisting radicular pain by using the same translaminar approach. 28 patients showed complete or nearly complete relief of radicular pain. Using this approach we have seen no major complication or clinical instability during a follow-up of at least one year. The translaminar approach is an effective and minimally invasive technique in both canalicular and cranio-dorsolateral disc herniations. It gives an additional possibility to avoid partial removal of the facet joints, can be performed in all lumbar segments and preserves structures important for segmental spinal stability. The approach allows access to the extruded disc fragment and intervertebral disc space comparable to classical approaches and is a frequently used operative technique in our department.

MRI-guided periradicular nerve root infiltration therapy in low-field (0.23-T) MRI system using optical instrument tracking

The purpose of this study was to evaluate the feasibility of the MRI-guided periradicular nerve root infiltration therapy. Sixty-seven nerve root infiltrations under MRI guidance were done for 61 patients suffering from lumbosacral radicular pain. Informed consent was acquired from all patients. A 0.23-T open-MRI scanner with interventional tools (Outlook Proview, Philips Medical Systems, MR Technologies, Finland) was used. A surface coil was used in all cases. Nerve root infiltration was performed with MRI-compatible 20-G needle (Chiba type MReye, Cook, Bloomington, Ind.; or Manan type, MD Tech, Florida). The evaluation of clinical outcome was achieved with 6 months of clinical follow-up and questionnaire. The effect of nerve root infiltration to the radicular pain was graded: 1=good to excellent, i.e., no pain or not disturbing pain allowing normal physical activity at 3 months from the procedure; 2=temporary, i.e., temporary relief of pain; 3=no relief of pain; and 4=worsening of pain. As an adjunct to MRI-guided positioning of the needle the correct needle localization by the nerve root was confirmed with saline injection to nerve root channel and single-shot fast spin echo (SSFSE) imaging. The MRI guidance allowed adequate needle positioning in all but 1 case (98.5%). This failure was caused by degeneration-induced changes in anatomy. Of patients, 51.5% had good to excellent effect with regard to radicular pain from the procedure, 22.7% had temporary relief, 21.2% had no effect, and in 4.5% the pain worsened. Our results show that MRI guidance is accurate and safe in performing nerve root infiltration at lumbosacral area. The results of radicular pain relief from nerve root infiltration are comparable to CT or fluoroscopy studies on the subject.

Microdecompression without fusion for radiculopathy associated with lytic spondylolisthesis.

Patients with symptomatic L-5 nerve root compression and associated lytic spondylolisthesis are commonly treated by bilateral wide posterior decompression and concomitant fusion, often accompanied by transpedicular instrumentation. More limited surgery aimed solely at the relief of nerve root compression offers the potential for significant relief of radicular pain while avoiding iatrogenic instability, thereby alleviating the need for arthrodesis with its increased surgical morbidity. Nine patients with unilateral radicular symptoms referable to the L-5 nerve root, minimal back pain, and a lytic pars lesion with mild spondylolisthesis underwent unilateral microdecompression on their symptomatic side without associated fusion. All patients obtained relief of radicular pain at both short- and long-term follow-up examination. One patient demonstrated increased back pain and, accordingly, the procedure is now recommended only for patients with no greater than a 25% spondylolisthesis. Unilateral microdecompression without stabilization is an effective and safe method for relieving radicular pain in patients with a lytic pars defect, a mild spondylolisthesis, and minimal back pain. This therapeutic option should be considered in select cases as an alternative to bilateral wide decompression with fusion and instrumentation.

Identification and Management of Radiculopathy

Proper identification of compressive radiculopathy is essential before any treatment can be undertaken. The differential recognition of different pain patterns, sensory symptoms, and neurologic deficits provides the clinical guide to specific nerve root involvement. Appropriate radiology and imaging must correlate with symptoms and signs. Management includes surgical intervention when indicated for relief of radicular pain and restoration of function.

Response to steroid and duration of radicular pain as predictors of surgical outcome.

Prolonged structural compromise of spinal nerve roots can lead to chronic changes that surgical decompression might not be able to reverse. In this study, it was hypothesized that if there were a reversible structural pain component, a steroid injected into the patient's symptomatic nerve root should provide temporary pain relief and that these patients should have a favorable surgical outcome. It also was hypothesized that duration of radicular symptoms would correlate inversely with surgical outcome. For postoperative relief of radicular pain, the results showed that patients with pain lasting less than 1 year had a positive surgical result (89%), regardless of response to steroid. Patients with pain lasting more than 1 year and who have had a positive response to steroid injected into the symptomatic nerve root (roots) had a positive surgical outcome of 85%. Patients who did not respond to the steroid and had pain for more than 1 year (95%) generally had a poor surgical outcome. Although the poor outcome in the last group might be explained in some cases by an inadequate structural correction, inadequate stabilization, or functional reasons, the majority of these failures represented irreversible changes in the neural structures.

The shoulder abduction test in the diagnosis of radicular pain in cervical extradural compressive monoradiculopathies.

The authors have observed a series of patients with cervical monoradiculopathies due to extradural compressive disease in whom clinical signs included relief of radicular pain with abduction of the shoulder. Of 22 patients requiring myelography for unremitting radicular pain, 15 experienced relief of pain with shoulder abduction. Thirteen patients showing this sign required surgery and all achieved a good result. Two patients were relieved with additional conservative measures. Pain relief obtained with this maneuver seems to occur by decreasing tension on the nerve root. This shoulder abduction relief sign has not been commonly elicited in the past, and the authors wish to bring attention to its value as an indicator of significant cervical extradural radicular compressive disease.

Surgical treatment of nerve root compression caused by scoliosis of the lumbar spine.

✓ Effective relief of radicular pain and recovery of function is reported in four elderly patients with lumbar scoliosis following surgical decompression of the lateral recesses of the spinal canal. The operation includes laminectomy or hemilaminectomy with unroofing of the lateral recesses and foramina by medial facetectomy or facetectomy. The patients tolerated surgery without morbidity, were walking within 2 or 3 days, and recovered without incident. The pathological anatomy and operative criteria are discussed.