Unilateral Leg Pain Research Articles

Clinical Classification of Patients With Lumbar Spinal Stenosis Based on Their Leg Pain Syndrome

Prospective follow-up and retrospective review of 174 patients surgically treated for degenerative lumbar spinal stenosis. To examine whether the type of leg pain syndrome associated with lumbar spinal stenosis is correlated with outcome. Although classifying patients based on their leg pain syndrome is useful in planning surgical decompression, there is no validated method of classification and its prognostic significance remains unknown. Based on the type of leg pain, the patients were classified into 2 groups: unilateral and bilateral. Improvement in functional status was evaluated using the Quebec Back Pain Disability Scale; the symptoms were rated on a visual analog scale and the change from baseline to 2-year evaluation was noted. Associations between score changes and baseline variables were examined using multivariate analysis. The type of leg pain was independently associated with improvements in function and leg symptom scores but was not associated with improvement in the back pain score. After surgery, patients with unilateral leg pain had significantly greater improvements in function and leg symptoms than patients with bilateral leg pain. In patients undergoing surgery for degenerative lumbar spinal stenosis, the preoperative type of leg pain predicts function and leg symptom outcomes.

An Oblique Paraspinal Approach for Intracanalicular Disc Herniations of the Upper Lumbar Spine: Technical Case Report

To present our experience of treating the central or paramedian disc herniations of the upper lumbar levels through a paraspinal approach. We present four patients with intracanalicular disc herniations at the L1-L2 or L2-L3 level. All patients had unilateral or bilateral radicular leg pain and motor weakness. Considering the unique characteristics of the upper lumbar spine, we performed the oblique paraspinal approach to expose the central portion of disc and removed the herniated disc effectively. Postoperatively, their symptoms were improved. There was no instability during the follow-up period. The oblique paraspinal approach for the treatment of central disc herniations at the upper lumbar levels is an effective nonfusion technique that preserves most of the facet joint and provides a wide surgical field.

Posterior Lumbar Interbody Fusion via a Unilateral Approach

This study sought to determine the outcomes of posterior lumbar interbody fusion (PLIF), via a unilateral approach, in selected patients who presented with unilateral leg pain and segmental instability of the lumbar spine. Patients with a single level of a herniated disc disease in the lumbar spine, unilateral leg pain, chronic disabling lower back pain (LBP), and a failed conservative treatment, were considered for the procedure. A total of 41 patients underwent a single-level PLIF using two PEEK™ (Poly-Ether-Ether-Ketone) cages filled with iliac bone, via a unilateral approach. The patients comprised 21 women and 20 men with a mean age of 41 years (range: 22 to 63 years). Two cages were inserted using a unilateral medial facetectomy and a partial hemilaminectomy. At follow-up, the outcomes were assessed using the Prolo Scale. The success of the fusion was determined by dynamic lumbar radiography and/or computerized tomography scanning. All the patients safely underwent surgery without severe complications. During a mean follow-up period of 26 months, 1 patient underwent percutaneous pedicle screw fixation due to persistent LBP. A posterior displacement of the cage was found in one patient. At the last follow up, 90% of the patients demonstrated satisfactory results. An osseous fusion was present in 85% of the patients. A PLIF, via a unilateral approach, enables a solid union with satisfactory clinical results. This preserves part of the posterior elements of the lumbar spine in selected patients with single level instability and unilateral leg pain.

Conus medullaris and cauda equina syndrome as a result of traumatic injuries: management principles

Conus medullaris syndrome (CMS) and cauda equina syndrome (CES) are complex neurological disorders that can be manifested through a variety of symptoms. Patients may present with back pain, unilateral or bilateral leg pain, paresthesias and weakness, perineum or saddle anesthesia, and rectal and/or urinary incontinence or dysfunction. Although patients typically present with acute disc herniations, traumatic injuries at the thoracolumbar junction at the terminal portion of the spinal cord and cauda equina are also common. Unfortunately, a precise understanding of the pathophysiology and optimal treatments, including the best timing of surgery, has yet to be elucidated for either traumatic CES or CMS. In this paper the authors review the current literature on traumatic conus medullaris and cauda equina injuries and available treatment options.

Factors predicting the prognosis of lumbar radiculopathy due to disc herniation

This study was designed to determine the prognostic factors in unilateral lumbar radiculopathy due to herniated nucleus pulposus (HNP); this was done by prospectively investigating the clinical course of consecutive patients with HNP. The study population consisted of 131 patients who complained primarily of unilateral leg pain, and who were examined by magnetic resonance imaging (MRI) to establish a definite diagnosis. Patients with a questionable diagnosis were excluded. The initial assessment was done within the first 2 months of presentation, according to conventional surgical indications. Surgery was performed only in patients who gave their informed consent for the procedure. Questionnaires were sent to patients twice, in 1994 and 1996, to assess the clinical outcome in those patients who did not meet the surgical indications and in those who met the indications, but who refused surgery. Clinical outcomes were classified into three categories based on the patients’ own assessment. Fifty patients met the surgical indication criteria, and 25 were actually operated on. Neither these patients’ profiles nor their MRI findings correlated with the results of the initial assessment. Patient age was significantly correlated with outcome only at the time of the first follow-up. The type of HNP and the result of the initial assessment were correlated with outcome at the times of both follow-ups, but the significance of these correlations had decreased at the second follow-up. In conclusion, initial assessment and type of HNP on MRI are major prognostic factors. However, the conventional manner of treatment selection is inadequate for the appropriate management of lumbar disc herniation.

The Short-Term Effect of Lumbar Positional Distraction

The purpose of this study was to test the hypothesis that positional distraction provides immediate relief of unilateral leg pain suspected to be caused by lumbar-nerve root irritation. Thirty subjects with true neurological signs were randomly assigned to a treatment group or control group. The treatment group received positional distraction for five minutes and the control group lay in side-lying for the same amount of time. Pain intensity, pain location, and SLR test height data was taken pre- and post-test. Statistical analysis was completed with the Wilcoxin-signed rank test for the data of pain intensity and with the paired sample t-test for the SLR height. The treatment group was found to have significantly less pain, more centralization of pain, and an increase in SLR test height (p-values of 0.001, 0.006, and 0.005 respectively). The control group showed no significant change (p-values of 0.506, 0.480, 0.884).

Efficacy of Transverse Tripolar Stimulation for Relief of Chronic Low Back Pain

The goal of this study was to evaluate the efficacy of the transverse tripolar spinal cord stimulation system (TTS) in providing relief of low back pain in patients with chronic non-malignant pain. Transverse tripolar electrodes were implanted in the lower thoracic region (T_8–9 to T₁₂–L₁) in 10 patients with chronic neuropathic pain, all of whom reported a significant component of low back pain in combination with unilateral or bilateral leg pain. One patient reported inadequate pain relief during the trial and was not implanted with a permanent generator. A visual analogue scale of low back pain showed a nonsignificant decrease from 64 ± 19 to 47 ± 30 (p = 0.25; paired t test) after 1 month of stimulation. Similarly, functional disability evaluated using Oswestry Low Back Pain Questionnaire was not improved (p = 0.46; paired t test). We conclude that chronic low back pain is not particularly responsive to the transverse stimulation provided by the TTS system.

Clinical and pathologic characteristics of lumbar disk herniation in the elderly.

The clinical and pathologic characteristics of lumbar disk herniation in 23 elderly patients (15 men and 8 women) who required surgical treatment were investigated. Average age at surgery was 67.3 years, and average follow-up was 23 months. Preoperatively, the predominant symptom was severe unilateral leg pain, and 13 patients were nonambulatory because of leg pain. Operative treatment included wide laminectomy in 8, hemilaminectomy in 3, fenestration in 10, and osteoplastic laminectomy in 2 patients. Four (17%) patients had disk herniation at the L2-L3 or L3-L4 level. Sequestered herniation with or without migration was observed in 15 (65%) patients. Of 14 sequestered disk fragments examined histologically, 8 (57%) specimens contained cartilaginous or bony end plate with anulus fibrosus or nucleus pulposus. Postoperatively, results were rated as excellent in 11 patients and good in 12; no patient was rated as fair or poor. Severe leg pain affecting activities of daily life is a predominant symptom of disk herniation in the elderly. For patients in whom conservative treatment has failed, operative treatment should be considered. In lumbar disk herniation in the elderly, the incidence of cephalad and lateral herniation is higher than in younger patients. In addition, sequestered and migrated herniations including end plate are frequent.

Long-term follow up of patients surgically treated by the far-lateral approach for foraminal and extraforaminal lumbar disc herniations.

This study was undertaken to evaluate the long-term benefit in 202 patients who were surgically treated via a microsurgical far-lateral approach for foraminal or extraforaminal lumbar disc herniations. All patients underwent surgery at the authors' institute since 1987 and represented 6.5% of all lumbar spinal disc surgeries. There were 67 women and 135 men who ranged in age from 19 to 78 years (mean age 58 years). All patients had unilateral leg pain due to lumbar disc herniations into or lateral to the lateral interpedicular compartment. One patient underwent surgery at the L1-2 level, nine at L2-3, 48 at L3-4, 86 at L4-5, and 58 at the L5-S1 level. The mean follow-up period was 50 months (range 12-120 months). Outcome was defined as excellent (no pain), good (some back pain), fair (moderate radiculopathy), and poor (unchanged or worse) based on Macnab classification. Overall, excellent and good results were achieved in 62 (31%) and 85 (42%) patients, respectively, and fair and poor results in 40 (20%) and 15 (7%) patients, respectively. Of 11 recurrent disc herniations, four presented in an extreme-lateral position, five in a paramedian location, and two on the contralateral side. There were three minor complications related to surgery, seven general complications, and no case of spinal instability. The far-lateral approach is a safe, effective procedure that avoids the risk of secondary spinal instability.

Familial predisposition for lumbar degenerative disc disease. A case-control study.

A case-control study using magnetic resonance imaging and plain radiography to evaluate whether a family history of lumbar disc herniation is a risk factor for disc degeneration. To evaluate the significance of a family history of operated lumbar disc herniation in the development of lumbar disc degeneration and lumbar disc herniation. There are only a few epidemiologic studies indicating that a family history of intervertebral disc herniation is a risk factor for juvenile disc herniation. Recently, similarities in degenerative findings of the lumbar spine between identical twins have been reported. In the case group, 24 patients who were the immediate relatives of patients who had undergone surgery for disc herniation and who presented or had a history of low back pain and/or unilateral leg pain were included. Control individuals included 72 age- and gender-matched outpatients who reported low back pain and/or leg pain without a family history of operated disc herniation. The incidence, level, and topographic location of disc herniation/diffuse bulge; the incidence and grade of disc degeneration observed on magnetic resonance images; and degenerative changes suggesting disc degeneration observed on plain radiographs were compared between the relatives of patients with disc herniation (cases) and the controls. The incidence of disc degeneration at L4-L5 and L5-S1 in cases (L4-L5, 18/24; L5-S1, 18/24) and controls (L4-L5, 45/72; L5-S1, 43/72) was similarly high. However, the grade of disc degeneration according to magnetic resonance imaging signal intensity on the T2-weighted sagittal image using Schneiderman's four-grade classification was significantly more severe in cases (L4-L5: Grade 1, 6/24; Grade 2, 4/24; Grade 3, 13/ 24; Grade 4, 1/24; L5-S1: Grade 1, 6/24; Grade 2: 3/24, Grade 3: 12/24, Grade 4: 3/24) than in controls (L4-L5: Grade 1, 27/72; Grade 2, 24/72; Grade 3, 20/72; Grade 4, 1/72; P = 0.034; L5-S1: Grade 1, 29/72; Grade 2, 23/72; Grade 3, 13/72; Grade 4, 7/72; P = 0.023; Mann-Whitney U test). The incidence of disc herniation/diffuse bulge at L4-L5 (16/24) and L5-S1 (11/24) in cases was higher than that in controls (L4-L5, 33/72; P = 0.07; L5-S1, 17/ 72; P = 0.04; chi-square test). The current study provided evidence that a family history of operated lumbar disc herniation has a significant implication in lumbar degenerative disc disease. There may be a genetic factor in the development of lumbar disc herniation as an expression of disc degeneration.

Contrast-enhanced magnetic resonance imaging in conservative management of lumbar disc herniation.

This study was designed to investigate the morphologic changes in contrast-enhanced magnetic resonance imaging that occur during conservative treatment of patients with unilateral leg pain resulting from herniated nucleus pulposus without significant lumbar canal stenosis. To compare the morphologic results with clinical outcomes to ascertain whether enhanced magnetic resonance imaging contributes to the management of lumbar disc herniation. Contrast-enhanced magnetic resonance imaging has already been reported to be useful in the postoperative examination of the lumbar spine and in visualization of symptomatic nerve roots. However, there have been few reports about its usefulness in the conservative management of herniated nucleus pulposus or about the correlation between herniated nucleus pulposus regression and enhanced effect. The study population consisted of 48 patients with radiculopathy. All patients primarily reported unilateral leg pain, and 94% had positive tension signs. Additionally, 38% exhibited muscle weakness corresponding to the symptomatic nerve root. All patients were studied twice or more using gadolinium-magnetic resonance imaging during conservative therapy, at a mean interval of 191 days. Changes in the size of the herniated nucleus pulposus on precontrast images fell into four categories, with changes in enhancement on postcontrast images classified into two categories: "enlargement" and "no change." In all cases of migrating type herniated nucleus pulposus, circular enhancement was seen on postcontrast images. In 17 of 22 cases, the enhanced area gradually thickened and intruded into the migrated disc materials as the size of the herniated nucleus pulposus decreased; the herniated nucleus pulposus disappeared in nine cases and showed a marked decrease in seven cases. These cases showed good clinical courses of sciatica. In the other five patients, in whom there were no changes in the enhanced area, there was less of a tendency for the herniated nucleus pulposus to decrease in size, and there were poorer clinical results. In six cases of extruding-type herniated nucleus pulposus, no enhanced effects were observed throughout the follow-up period. The other 20 cases showed enhancement that was relatively weaker than that of migrating disc herniation. Extension or expansion of the enhanced area was observed in the follow-up images of 15 cases, though only four showed obvious changes in the size of the herniated nucleus pulposus. These 15 cases had better clinical results than the other cases, in which enhanced effects did not change or were not observed. Contrast-enhanced magnetic resonance imaging is a useful prognostic parameter, and multiple use contributes to the proper management of lumbar disc herniation.

Hemi-cauda equina syndrome from herniated lumbar disc: a neurosurgical emergency?

We report experience with patients presenting with a specific combination of symptoms: unilateral sciatica, unilateral sensibility loss in the dermatomes S1 to S5 (hemi-saddle) and subjective micturation problems secondary to ruptured lumbar disc. Because of its similarities with a cauda equina syndrome, this combination of symptoms was thought to be a unilateral cauda equina syndrome and it was called hemi-cauda equina syndrome. Consequently, it was treated as an emergency. Ten patients were evaluated. They compromised 2.3% of all patients undergoing lumbar discectomy. Outcome is good with only 10% persisting minor neurologic deficit (sensibility loss in dermatomes S3 to S5). With the exception of urinary retention or incontinence, duration of symptoms and signs does not seem to influence outcome. Comparing signs, symptoms and radiographic findings with those of a cauda equina syndrome which were recently and thoroughly studied, they were found to be more severe in cases of cauda equina syndrome. Especially, the good outcome, (apparently unrelated to the duration of symptoms in cases of hemi-cauda equina syndrome) contrasted with the treatment results of cauda equina syndrome. We defined the hemi-cauda equina syndrome from ruptured disc as a combination of unilateral leg pain, unilateral sensibility loss in dermatomes S1 to S5 and sphincter paralysis (proven urinary retention or incontinence). Motor deficit is not necessarily present. Emergency surgery is warranted. Patients presenting with micturation complaints other than urinary retention or incontinence do not suffer from a hemi-cauda equina syndrome.

The natural history of herniated nucleus pulposus with radiculopathy.

The present study retrospectively investigated the morphologic changes that occurred during conservative treatment of patients with unilateral leg pain resulting from herniated nucleus pulposus without significant lumbar canal stenosis. The results were correlated with clinical outcomes and extruding forms to determine which type of herniated nucleus pulposus had the greatest capacity for spontaneous regression and how rapidly such regression might occur. The study population consisted of 77 patients with radiculopathy. All patients complained primarily of unilateral leg pain, and 94% had positive tension signs. Additionally, 32% exhibited muscle weakness corresponding to the symptomatic nerve root. All patients were studied more than twice using magnetic resonance imaging during conservative therapy at a mean interval of 150 days. Morphologic changes on magnetic resonance imaging fell into four categories, with herniated nucleus pulposus classified into three types using T1-weighted sagittal views. Each patient was reexamined on the same scanner; 53 patients were examined twice, and 24 patients were examined more than three times. Morphologic changes, with the exception of 13 false-negative cases, basically corresponded to clinical outcome. In half of the cases that showed some improvement at follow-up evaluation, improvement of clinical findings were seen before those observed on magnetic resonance imaging. Migrating herniated nucleus pulposus frequently presented an obvious decrease in size, and even disappearance in seven cases. The further the herniated nucleus pulposus migrated, the more decrease in size could be observed. The cases apparently corresponding to "protrusion" showed little or no change on follow-up magnetic resonance imaging. Regarding the mechanism of herniated nucleus pulposus disappearance, exposure to the vascular supply undoubtedly took a part, although many factors were suspected to have some influence. Morphologic changes on magnetic resonance imaging mainly corresponded to clinical outcomes but tended to lag behind improvement of leg pain. Disappearance of herniate nucleus pulposus was seen frequently in the cases of migrating disc herniation, and it was presumed that exposure to the vascular supply had a lot to do with this phenomenon.

Surgery for patients with central protruded lumbar discs who have failed conservative therapy.

The clinical presentation and results of surgery of patients with central protruded lumbar discs have not been well defined or distinguished from studies of patients with lateral herniated discs. Many patients are denied surgical treatment, even though they are incapacitated by pain, because they do not have the classic radiographic findings seen in patients with lateral disc herniation. Sixty-three symptomatic patients with radiographically documented central lumbar disc protrusion were analysed. All patients had failed at least 6 months of conservative therapy. Although lumbar spinal pain was the most common complaint, 24 patients also presented with bilateral leg pain and 33 with unilateral leg pain; 26 had unilateral limitation of straight leg raising. An interesting observation was that unilateral symptoms and dural tension signs can be seen in patients with central disc protrusion. After surgical follow-up for a mean of 51 months, 86% achieved good results when analysed by the Prolo Functional Economic Outcome Rating Scale. It is postulated that pain is mediated by neuropeptides and arachidonic acid degradation products which are a response to mechanical annular injury.

Percutaneous Lumbar Diskectomy

The development of an approach for percutaneous lumbar diskectomy (PLD) began over 20 years ago. Since then, clinical investigations of manual and automated PLD techniques have recorded an average success rate of 50% to 70%. Currently, the indications for PLD include (1) a major complaint of acute unilateral leg pain localized to a single dermatome associated witha a single-disk herniation; (2) neurologic signs or symptoms appropirate to a single-disk herniation; (3) magnetic resonance imaginng, computed tomographic, or diskographic evidence of a single herniation contained within the annulus of the lumbar disk; and (4) failure of a well-managed course of conservative treatment to relive the pain and symptoms. Conventional laminotomy/laminectomy, with or without the use of a microscope or surgical loupes, remains the usual method of surgical care for symptomatic lumbar disk disease. The role of PLD awaits further prospective randomized controlled studies.

The results of surgical treatment of lumbar arachnoiditis.

Forty patients with lumbar arachnoiditis, following previous operations, were classified into 4 myelographic types. Most patients with type I images had herniated disc symptoms with unilateral leg pain and limited straight-leg raising. Patients with types II and III myelographic appearances had bilateral leg pain, absent ankle jerks, weakness, cramps and signs of diffuse sensory deficit; some also had neurogenic claudication and urinary sphincter dysfunction. All patients with type IV had dysesthesia. Twenty-three of the 40 patients underwent reoperation and those with types I and II had acceptable results, but poor results occurred in those with types III and IV myelograms.

Presenting Symptoms of Neoplastic Spinal Cord Compression

The cases of 28 patients with neoplastic spinal cord compression were reviewed. The most common presenting symptoms were: back pain (68%), bilateral leg weakness (61 %), urinary retention (36%), and bilateral leg numbness (32 %). Twelve patients (43 %) had known neoplastic disease prior to diagnosis of spinal cord compression. Only two patients (7%) were diagnosed within one week of the onset of major spinal symptoms. The commonest symptoms associated with delay in diagnosis were again back pain (50%) and bilateral leg weakness (38%). However, when certain symptoms were present, diagnosis was almost always delayed, particularly with unilateral leg weakness or pain (loo%), ataxic gait (go%), and back pain (68%). Symptoms in the neck, chest, and arms were also always associated with delayed diagnosis.

変性性腰部脊柱管狭窄症の病態と手術的治療

768 cases of lumbar canal stenosis were surgically treated for the past 10 years. 321 cases of these operated cases were degenerative lumbar canal stenosis. About 116 cases passed over 5 years after operation and answered enqete (containing 72 consulted cases). Clinical symptoms and signs, operative findings, postoperative evaluation and roentgenologic changes were mainly investigated. The results were as follows:1) Clinical symptoms and signs: Unilateral leg pain (72%), cauda equina claudication (49%), limited motion in extension (71%), leg pain in extension (71%), muscle weakness (49%) and hypoactive or absent ATR (49%) were found in high frequency.2) Postoperative results: “Excellent” and “Good” cases accounted for 72%. In cases of duration of symptom over 3 years, operated at 60 years of age, at postoperative results tended to be poor 8 years after operation.3) Roentgenologic study was performed on 25 cases of wide laminectomy without fusion. In these cases, anterior displacement was found in 20% of L4+5 level laminectomy, and 66.7% of L3+4+5 level laminectomy, but correlation between displacement and postoperative results was not encountered.

Presenting symptoms of neoplastic spinal cord compression.

The cases of 28 patients with neoplastic spinal cord compression were reviewed. The most common presenting symptoms were: back pain (68%), bilateral leg weakness (61%), urinary retention (36%), and bilateral leg numbness (32%). Twelve patients (43%) had known neoplastic disease prior to diagnosis of spinal cord compression. Only two patients (7%) were diagnosed within one week of the onset of major spinal symptoms. The commonest symptoms associated with delay in diagnosis were again back pain (50%) and bilateral leg weakness (38%). However, when certain symptoms were present, diagnosis was almost always delayed, particularly with unilateral leg weakness or pain (100%), ataxic gait (80%), and back pain (68%). Symptoms in the neck, chest, and arms were also always associated with delayed diagnosis.

Sciatic entrapment neuropathy

A case of sciatic entrapment neuropathy is discussed. When evaluating patients with unilateral leg pain and paresthesias, one should consider the possibility of entrapment of peripheral nerve. Electrodiagnostic studies are helpful in establishing the diagnosis.