Lumbar nerve root compression at the intervertebral foramina caused by arthritis of the posterior facets

The Change of Lumbar Spinal Stenosis Symptoms over a Six-Year Period in Community-Dwelling People

Background and Objectives: The high prevalence of lumbar spinal stenosis (LSS) and its negative impact on quality of life in the elderly is well known. However, the longitudinal time course of LSS symptoms remains unclear. The purpose of this study was to clarify the longitudinal time course and associated factors of LSS symptoms over a period of six years in a community. Materials and Methods: This study was conducted with data prospectively collected in 2004 and 2010 under a retrospective design. In 2004, 1578 subjects (age range: 40 to 79 years) were interviewed on LSS symptoms using a specially designed and validated questionnaire. In 2010, a follow-up study was performed by mail, to which 789 subjects of the 2004 study population responded. Considering that the presence of osteoarthritis (OA) of the knee or hip may influence the participants’ answers in the questionnaire, analysis was performed in all 789 subjects with and 513 subjects without either knee or hip OA. Changes in LSS symptoms between the initial and the 6-year survey were investigated. Multiple logistic regression analysis was used for detecting the risk factors for LSS symptom presence at the six-year follow-up. Results: 1. At the six-year follow-up, more than half of the subjects who showed LSS symptoms at the initial analysis became LSS-negative, and 12–15% of those who were LSS-negative became LSS-positive. 2. From the multiple logistic regression analysis, a lower Roland-Morris Disability Questionnaire (RDQ) score and a positive LSS symptom at the initial analysis were detected as predictive factors of the presence of LSS symptoms at the six-year follow-up in the total number of subjects, as well as just in those who did not have either knee or hip OA. Conclusions: More than half of the subjects who were LSS-positive at their initial assessment still experienced improvement in their symptoms even after 6 years. This means that both LSS symptoms and their time course vary from person to person. Predictive factors for the presence of LSS symptoms during the six-year follow-up period were RDQ score and positive LSS symptoms.

Excessive swelling of nerve roots : Important factor for recurring sciatica after lumbar surgery

OBJECTIVE

The aim of the study was to investigate the occurrence of unexpectedly swollen nerve roots and to investigate the relationship between nerve root edema and recurrent radicular pain.

METHODS

During the period from August 2010 to August 2015, a total of 462 patients with degenerative lumbar disease underwent surgery in this study group. Magnetic resonance imaging (MRI) was used to evaluate the details of the nerve root. Of the patients with recurring radiating pain 13 met the inclusion criteria of the study group and 24 patients without any complications volunteered as the control group. The visual analog scale (VAS), Oswestry Disability Index (ODI), and medical outcomes study item short form health survey (SF-36) were used to evaluate the clinical outcomes.

RESULTS

The preoperative diameter of the nerve root showed no significant difference between the two groups (P = 0.28). The postoperative nerve diameter of the study group was larger than that of the control group (P < 0.01). The initial operation improved the symptoms and the VAS was significantly decreased (P < 0.01). After recurrence of the neuralgia, the VAS score significantly increased (P < 0.01). The pain of the study group improved to the same level as that of the control group 4 weeks after subsequent surgery (P = 0.47), while the quality of life was still lower than that of the control group (P < 0.05). The scores collected 3 months after surgery showed that the clinical outcomes were not different between the two groups (P > 0.05).

CONCLUSION

In surgery for degenerative lumbar disease accompanied by nerve root edema, excessive nerve root swelling is an important factor for recurrent radiating pain. With a properly carried out intervention in the re-exploration, the recurrent symptoms can be gradually relieved.

The evolution of partial undercutting facetectomy in the treatment of lumbar spinal stenosis

Decompression of lumbar spinal stenosis is the most common spinal surgery in those over 60 years of age. While this procedure has shown immediate and durable benefits, improvements in outcome have not changed significantly. Technical aspects of surgical decompression have evolved significantly. The recently introduced ultrasonic bone cutter allows a precise and safe peri-neural bone resection. The principles of preservation of stability, as described by Getty et al. have remained as relevant as when these were described 40 years ago.

Prospective one-year follow-up of lumbar spinal stenosis in a regional community

Purpose

Lumbar spinal stenosis (LSS) is a common condition in the aging population. However, limited information exists on discrepancies between LSS symptoms and imaging findings and/or prognostic factors of LSS, as well as the relationship between changes in LSS symptoms and quality of life (QoL) during the natural course of LSS. The purpose of the current study was to clarify any changes in clinically diagnosed LSS at a one-year follow-up, and identify its prognostic factors, using a community-dwelling cohort.

Participants and methods

In this study, the presence of LSS, its associated comorbidities, and the status of QoL pertaining to general health and low-back pain were assessed in 1,080 community-dwelling volunteers. The same assessment was carried out a year after the initial survey. Clinically diagnosis as LSS (LSS-positive) was determined by a validated diagnostic support tool in the form of a self-administered, self-reported history questionnaire. QoL was assessed using the 36-Item Short Form Health Survey and the Roland-Morris Disability Questionnaire.

Results

Among subjects who were LSS-positive in the initial assessment, 54% were clinically diagnosed as negative for LSS (LSS-negative) after the one-year period, whereas 10% of those who were initially diagnosed as LSS-negative changed to LSS-positive during the same period. With the improvement or deterioration of LSS-positive/negative status, low-back pain-related QoL and some components of the 36-Item Short Form Health Survey similarly improved or deteriorated. Decisive prognostic factors of LSS-positive status were not determined at the one-year follow-up.

Conclusion

Approximately half of the subjects who had initially been diagnosed as LSS-positive converted to LSS-negative after one year. Prognostic factors of LSS-positive diagnosis after one-year follow-up were not detected.

Management of degenerative lumbar spinal stenosis: an evidence-based review

Lumbar spinal stenosis has become one of the most disabling pathologies in the elderly population.Some additional conditions such as foraminal stenosis or degenerative spondylosis with a history of back pain and leg pain must be considered before treatment.A completely appropriate protocol and unified management of spinal stenosis have not yet been well defined.The objective of this literature review is to provide evidence-based recommendations reflected in the highest-quality clinical literature available to address key clinical questions surrounding the management of degenerative lumbar spinal stenosis. Cite this article: Covaro A, Vilà-Canet G, García de Frutos A, Ubierna MT, Ciccolo F, Caceres E. Management of degenerative lumbar spinal stenosis: an evidence-based review article. EFORT Open Rev 2016;1:267-274. DOI: 10.1302/2058-5241.1.000030.

Targeted Intraspinal Radiofrequency Ablation for Lumbar Spinal Stenosis

Introduction

By using a combination of magnetic resonance imaging (MRI) and computed tomography (CT) of the lumbar spine, it is possible to distinguish between spinal stenosis caused by bone compression and specific soft tissue epidural intraspinal lesions that cause localized spinal canal stenosis and neural compression. Examples include facet cysts and yellow ligament hypertrophy. Many of these patients are elderly with medical comorbidities that make open surgery problematic.

Materials & Methods

This is a study of patients with predominantly soft tissue stenosis being treated with targeted intraspinal radiofrequency (RF) heat ablation. This novel procedure is performed under local anesthesia in an outpatient setting using intra-operative imaging. Fine tip 20 gauge RF electrodes (Stryker® PA, USA) are precisely placed under radiologic guidance in the identified soft tissue causing the posterior compression of the lumbar spinal canal. After sensory and motor testing to make sure there is a safe distance of the needle tip from the nearby nerve roots to avoid any neural effect, multiple targeted lesions correlated by the MRI or CT scan are made in the fibrous and cystic soft tissue. Lesions are created using a focused 2 or 5 mm tip at 60 degrees centigrade (°C) for either 30 or 60 seconds. This heat causes sufficient shrinking of the targeted soft tissue resulting in relative reduction of the soft tissue component of the stenosis. This relative reduction in the stenosis of the spinal canal, similar to that measured with interspinous devices, provides long-term relief of symptoms, signs, and improvement of spinal motion in patients with lumbar stenosis. This report will review the spinal anatomy, and development and history of using RF in and around the nerve roots and epidural space, as it relates to lumbar stenosis. Examples of before and after MRI scans demonstrate the radiologic reduction in the size of the lesions. This soft tissue reduction correlates with patients' improvement in pain and clinical symptoms. Follow-up of the patients up to 30 months shows that the effect of RF heat on the soft tissue is long lasting.

Results

In our long-term follow-up of greater than six months, 58% of RF treated patients had lasting relief of clinical symptoms, back pain, and claudication with increased spinal movement. This reduction in pain and improvement in motion allows patients to continue more aggressive physical therapy and muscle strengthening that secondarily can improve their symptoms. Post-procedure follow-up MRI scans in multiple patients have shown a clear reduction in soft tissue lesion size. Long-term follow-up demonstrated that 58% of patients treated with RF targeted ablation have not required further intervention and 22% went on to other surgical treatments for lumbar spinal stenosis.

Conclusion

By reducing the soft tissue component of the stenosis with RF ablation and creating relatively more epidural space, targeted intraspinal RF may be a possible minimally invasive, percutaneous non-surgical alternative to treatment in a number of patients where soft tissue lumbar stenosis is the main cause of patients' symptoms. This technique offers a simple and safe additional method to relieve symptoms of lumbar stenosis and possibly compression within the neural foramina, especially in the elderly.

Minimally invasive percutaneous endoscopic 2 levels adjacent lumbar discectomy through 1 portal skin incision: Preliminary study

Background:

Acute lumbar disc herniation can occur in every lumbar intervertebral disc space and in multiple levels simultaneously. In the cases of 2 levels adjacent lumbar disc herniations of severe unilateral radiculopathic leg pain caused by compression of the nerve roots, respectively, multiple incision or long incision is generally needed for simultaneous removal of disc fragment in 2 levels.

Objectives:

We proposed the minimally invasive one portal skin incision endoscopic discectomy is effective and safe method to treat 2 levels adjacent lumbar disc herniation.

Materials and Methods:

We have experimented total 8 cases of 2 levels adjacent lumbar disc herniation having unilateral radiculopathic pain respectively. All cases are 2 levels adjacent lumbar disc herniation. We have tried a percutaneous endoscopic transforaminal approach through minimal one portal skin incision and remove the two herniated disc materials in the adjacent levels.

Results:

The L2-L3 level was involved in 2 patients, L3-L4 level in 6 patients, while the L4-L5 level was involved in 7 patients, L5-S1 level in 1 patient. The mean follow-up was 18.5 months. The mean visual analogue score (VAS) of the patients prior to surgery was 7.75, and the mean postoperative VAS was 2.375. According to Macnab's criteria, 3 patients had excellent results, 4 patients had good results, 1 patient had fair results, and no patient had a poor result; satisfactory results were obtained in 87.5% of the cases.

Conclusion:

The percutaneous endoscopic transforaminal approach through 1 skin portal incision could be effective surgical method in unilateral adjacent 2 levels lumbar disc herniation.

Comparison between walking test and treadmill test for intermittent claudication associated with lumbar spinal canal stenosis

PURPOSE

To clarify the priorities of the walking test and the treadmill test for intermittent claudication of lumbar canal stenosis.

METHODS

The study population comprised 45 subjects, with a mean age of 72.6 years. An investigator walked with the subjects during the walking test or watched the subjects walking on the treadmill machine in the treadmill test.

RESULTS

The pain scales became significantly worse after the walking test. Ten patients who were diagnosed as root symptom type or cauda equine symptoms were subsequently diagnosed as mixed type by the walking test. The numbers of patients who experienced muscle weakness that was not revealed at rest were eight with the walking test and seven with the treadmill test. The numbers of patients who experienced sensory disturbance that was not observed at rest were seven with the walking test and two with the treadmill test.

CONCLUSIONS

The walking test detected significantly more symptoms that were not detected at rest than the treadmill test.

Lumbar spinal stenosis has a negative impact on quality of life compared with other comorbidities: an epidemiological cross-sectional study of 1862 community-dwelling individuals

Lumbar spinal stenosis (LSS) is common in the elderly. However, there have been few reports on its impact on quality of life (QoL) in community-dwelling individuals. The purpose of this study was to clarify how symptomatic LSS affects QoL at the community level. A total of 1862 people (697 males and 1165 females, most subjects were between 40 and 85 y.o.) agreed to participate and were interviewed. The presence of symptomatic LSS was assessed by a specially designed questionnaire. The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) was also administered. In addition, the presence of comorbid conditions that affect QoL, such as osteoarthritis of the knee and hip, cardiovascular disease, cerebrovascular disease, or respiratory disease, was also analyzed. The prevalence of symptomatic LSS gradually increased with age. Furthermore, the presence of symptomatic LSS had a strong negative effect on all 8 physical and mental domains and the physical component summary (PCS) (OR: 1.547–2.544) but not the mental component summary (MCS). In comparison with comorbid conditions, LSS had a much stronger negative impact on health-related QoL (HR-QoL). The current study confirmed that the presence of symptomatic LSS might have a strong negative influence on HR-QoL in the community setting.

A less invasive surgical approach in the lumbar lateral recess stenosis: direct approach to the medial wall of the pedicle

The lateral recess is one of the main compression sites in lumbar spinal canal stenosis. Lumbar nerve root is mainly entrapped by bony tissue in compression syndrome. The patient has a long history of back pain in conjunction with claudication symptoms. Besides laminotomy and facetectomy techniques, several specific surgical approaches to treat the lateral recess stenosis have been described. The surgical technique of bilateral lateral recess decompression via subarticular fenestrations used in this study is a less invasive technique, which enables to decompress the neural structures while preserving as much of the bony structures and ligamentum flavum as preferred. In 16 patients, we measured lateral recess heights with computerized tomography. The number of involved lumbar segments was one in 11 patients and two in 5 patients. The visual analogue scale (VAS) results were maintained before, 3 and 12 months after the operation. All patients benefited from the operations. Mean VAS scores were 7.0, 5.5, and 4.0, respectively. There were not any surgery-related complications. Mean follow-up period is 22.6 months. The surgical technique described and used in this study provides easy access to every zone of lateral recess and is safe and effective in treating the lumbar lateral recess stenosis syndrome.

Biomechanics of the lumbar spine after dynamic stabilization

Target of the study was to predict the biomechanics of the instrumented and adjacent levels due to the insertion of the DIAM spinal stabilization system (Medtronic Ltd). For this purpose, a 3-dimensional finite element model of the intact L3/S1 segment was developed and subjected to different loading conditions (flexion, extension, lateral bending, axial rotation). The model was then instrumented at the L4/L5 level and the same loading conditions were reapplied. Within the assumptions of our model, the simulation results suggested that the implant caused a reduction in range of motion of the instrumented level by 17% in flexion and by 43% in extension, whereas at the adjacent levels, no significant changes were predicted. Numerical results in terms of intradiscal pressure, relative to the intact condition, predicted that the intervertebral disc at the instrumented level was unloaded by 27% in flexion, by 51% in extension, and by 6% in axial rotation, while no variations in pressure were caused by the device in lateral bending. At the adjacent levels, a change of relative intradiscal pressure was predicted in extension, both at the L3/L4 level, which resulted unloaded by 26% and at the L5/S1 level, unloaded by 8%. Furthermore, a reduction in terms of principal compressive stress in the annulus fibrosus of the L4/L5 instrumented level was predicted, as compared with the intact condition. These numerical predictions have to be regarded as a theoretical representation of the behavior of the spine, because any finite element model represents only a simplification of the real structure.

Comparison of radiologic signs and clinical symptoms of spinal stenosis

STUDY DESIGN

Clinical findings of spinal stenosis were compared to graded radiologic findings of dural sac narrowing.

OBJECTIVES

To examine the changes of the dural sac area of the lumbar spine on computerized tomography (CT) performed without and with axial loading, and study the correlations between the radiologic findings and clinical symptoms suggestive of spinal stenosis.

SUMMARY OF BACKGROUND DATA

Although several studies have been performed regarding the advantage of an external compression device in lumbar CT, to our knowledge, none of these studies have correlated radiologic findings with clinical symptoms.

METHODS

The cross-sectional areas of the dural sac at the 3 lowest lumbar intravenous spaces, measured by CT both without and with external compression, were correlated to the clinical symptoms suggestive of spinal stenosis in 117 patients and 351 intervertebral levels.

RESULTS

No statistically significant correlation between the severity of the clinical symptoms of spinal stenosis and dural cross-sectional areas was found. Neither did the use of an external compression device improve the correlation.

CONCLUSION

Although an external compression simulates the dynamic condition in the back during standing position, it does not eliminate the need to compare the radiologic findings with the clinical symptoms of patients examined because of a suspected narrowing of the spinal canal.

The positional magnetic resonance imaging changes in the lumbar spine following insertion of a novel interspinous process distraction device

STUDY DESIGN

Patients with symptomatic lumbar spinal stenosis underwent magnetic resonance imaging to study changes in the lumbar spine in various postures before and after implantation of the X STOP Interspinous Process Distraction Device (St. Francis Medical Technologies, Concord, CA).

OBJECTIVE

To visualize the effect of the device in vivo.

SUMMARY OF BACKGROUND DATA

Previous studies have shown vertebral canal and exit foraminal area to reduce from flexion to extension. Recently, reports on improved kinematics in vitro at the implantation level of the X STOP device have also been published.

METHODS

Using positional magnetic resonance imaging, patients were scanned before and 6 months after surgery. Images were taken with the patient in sitting flexed, extended, neutral, and standing positions. The total range of motion of the lumbar spine and individual segments were measured, along with changes in disc height, areas of the exit foramens, and dural sac.

RESULTS

In 12 patients with 17 distracted levels, the area of the dural sac at these levels increased from 77.8 to 93.4 mm after surgery in the standing position (P = 0.006), with increase in the exit foramens, but no change in lumbar posture.

CONCLUSIONS

This study shows that the X STOP device increases the cross-sectional area of the dural sac and exit foramens without causing changes in posture.

Unilateral removal of pars interarticularis

OBJECT

Lumbar radiculopathy secondary to foraminal entrapment can be treated by unilateral removal of the overlying pars interarticularis. The authors prospectively evaluated the outcome after this procedure.

METHODS

Thirty-six consecutive patients underwent unilateral resection of the pars interarticularis between August 1999 and July 2002. In 18 patients acute foraminal disc herniations compressed the nerve root against the superior pedicle; in the other 18 foraminal stenosis was secondary to degenerative changes. All patients, at each visit, completed the following questionnaires: visual analog scale for overall, leg, and back pain; the Prolo Functional Economic Rating scale; and the Pain Rating Index (PRI) of the Short-Form McGill Pain Questionnaire. At 1 year, leg pain improved in 33 patients (91%). Low-back pain appeared or worsened in eight patients (22%; one in the acute herniation group and seven in the chronic degenerative group). Only one patient required lumbar fusion for pain. The Prolo economic and function scores improved in 21 (58%) and 27 (75%) patients, respectively. The PRI scores improved in 30 cases (83%). No spondylolisthesis was observed at any level at which resection had been performed.

CONCLUSIONS

Unilateral removal of the pars interarticularis is effective in relieving lumbar radicular symptoms in patients with intraforaminal entrapment. The incidence of low-back pain in patients with acute foraminal disc herniations does not increase as a result of this procedure. In patients with degenerative foraminal stenosis, unilateral resection of the pars interarticularis may be a better alternative to facetectomy and segmental fusion. This procedure may be a useful tool in spine surgery.

Lumbar stenosis: a personal record

✓ Although its management continues to evolve, lumbar stenosis remains a common societal problem. The present article is based on an invited lecture at the 2004 Annual Meeting of the Congress of Neurological Surgeons/American Association of Neurological Surgeons Joint Section on Disorders of the Spine and Peripheral Nerves. In it the authors provide a historical overview of lumbar stenosis and describe how the senior author's treatment of this condition has evolved over the past four decades. Within each era of treatment, the reasons for modification of treatment methods and relevant outcome measures are outlined. Additionally, specific subsets of patients with lumbar stenosis are also discussed to emphasize unique characteristics that affect treatment strategies. The authors' present technique for management of lumbar stenosis is also illustrated.

Surgical management of lumbar stenosis: decompression and indications for fusion

Review of the clinical, neuroradiological, and surgical management of lumbar spinal stenosis reveals that 90 to 95% of congenital or acquired variants may be adequately managed by means of decompression without fusion. These decompressive procedures often simultaneously treat disc herniations, limbus fractures, degenerative spondylolisthesis, rare selected cases of spondylolisthesis accompanied by lysis in older patients, and degenerative scoliosis. Fusion should be reserved for the approximately 5 to 10% of patients in whom there is clinical evidence of instability prior to surgery or for the few who develop slippage following laminectomy and facetectomy.

The effects of an interspinous implant on the kinematics of the instrumented and adjacent levels in the lumbar spine

STUDY DESIGN

Measurement of the kinematics of the lumbar spine after insertion of an interspinous spacer in vitro.

OBJECTIVES

To understand the kinematics of the instrumented and adjacent levels due to the insertion of this interspinous implant.

SUMMARY OF BACKGROUND DATA

An interspinous spacer (X Stop, SFMT, Concord, California) has been developed to treat neurogenic intermittent claudication by placing the stenotic segment in slight flexion and preventing extension. This restriction of motion by the interspinous implant may affect the kinematics of levels adjacent to the instrumented level.

METHODS

Seven lumbar spines (L2-L5) were tested in flexion-extension, lateral bending, and axial rotation. Images were taken during each test to determine the kinematics of each motion segment. The interspinous implant was placed at the L3-L4 level, and the test protocol was repeated.

RESULTS

The flexion-extension range of motion was significantly reduced at the instrumented level. Axial rotation and lateral bending ranges of motion were not affected at the instrumented level. The range of motion in flexion-extension, axial rotation, and lateral bending at the adjacent segments was not significantly affected by the implant.

CONCLUSIONS

The implant does not significantly alter the kinematics of the motion segments adjacent to the instrumented level.

Biomechanical comparison of facet-sparing laminectomy and Christmas tree laminectomy

OBJECT

The authors compared differences in biomechanical stability between two decompressive laminectomy techniques for treating lumbar stenosis. A Christmas tree laminectomy (CTL), in which bilateral facetectomies and foraminotomies are performed, was compared with facet-sparing laminectomy (FSL), in which the facets are undercut but not resected. Spinal instability was assessed immediately postoperatively and again after discectomy to model long-term degeneration.

METHODS

Sixteen motion segments obtained from five human cadaveric lumbar specimens were studied in vitro by conducting nondestructive flexibility tests. Specimens were tested intact, after FSL or CTL, and again after discectomy. Nonconstraining torques (< or = 5 Nm) were applied to induce flexion, extension, axial rotation, and lateral bending; strings and pulleys were used while vertebral angles were measured. Anteroposterior translation in response to shear loading (< or = 100 N) was also measured. Angular motion, shear motion, and sagittal-plane axes of rotation were compared to evaluate stability. Compared with the intact condition, CTL-treated specimens had significantly larger increases in angular motion during flexion, lateral bending, and axial rotation than their FSL-treated counterparts (p < 0.05, nonpaired Student t-tests). Subsequent discectomy caused greater increases in motion in the CTL group. Axes of rotation shifted less from their normal positions after FSL than after CTL.

CONCLUSIONS

This study provides objective evidence that the treatment of lumbar stenosis with FSL induces less biomechanical instability and alters kinematics less than FSL. These findings support the use of the FSL in treating lumbar stenosis.

Effect of lumbar disc herniation on clinical symptoms in lateral recess syndrome

This study investigated the differences in the clinical features of lateral recess syndrome attributable to the bony entrapment of the spinal nerve root under the superior articular facet, and lateral recess syndrome and associated lumbar disc herniation. Ninety patients with pure bony entrapment (47 men, 43 women) ranging in age from 19 to 83 years (mean age, 63 years) and 59 patients with lumbar disc herniation in the lateral recess (43 men, 16 women) 19 to 85 years of age (mean age, 49 years) were included in this study. All patients had L5 root radiculopathies and were treated surgically. Although the early symptoms of patients with lateral recess syndrome often were in the lower extremities, many of the patients with associated lumbar disc herniation had a transition initially experiencing low back pain and subsequently having lower extremity symptoms. Flexion and extension of the lumbar spine exacerbated symptoms, particularly in patients with lumbar disc herniation. The results of the current study show that the clinical presentation of lateral recess syndrome differs depending on the cause of the compression in the lateral recess.

Degenerative spondylolisthesis in ancient and historic skeletons from New Mexico Pueblo sites

The objective of this study was to identify the presence of degenerative spondylolisthesis in adult Native American skeletons recovered from prehistoric and historic Pueblo sites in New Mexico. The vertebral columns of 491 individuals that were complete enough to allow the necessary observations produced 64 cases, with a total of 74 affected levels. The L5-S1 level was affected most frequently (78%), in contrast to clinical and anatomical studies where the L4-L5 level was usually affected (80%). Age and sex were found to be important factors, with the condition limited to middle and old adults, and occurring in females over males at a ratio of approximately 5:1. Olisthesis was shown to occur only in association with severe osteoarthritis of the zygapophysial joints, but severe osteoarthritis did not always result in olisthesis, particularly in males. Parallel or convergent inferior articular processes were found to increase in frequency in the presence of olisthesis, apparently resulting from degenerative remodeling that produced the olisthesis. The data also suggest that individuals with cranial border shifting in the column may be especially prone to olisthesis. Degenerative olisthesis was also observed in the cervical region.

Imaging lumbar spinal stenosis

The entire concept of spinal stenosis is based on the assumption that there is a minimal space necessary for the function of the neural content of the spinal canal, and this space, under certain circumstances, gets too small. This may seem self evident, but it was not until the middle of the previous century that there was sufficient focus on this concept to establish the diagnosis of lumbar spine stenosis.

Lumbosacral radiculopathy secondary to metastatic uterine leiomyosarcoma: a case report

STUDY DESIGN

A retrospective case report.

OBJECTIVES

To increase awareness of the fact that very serious and potentially devastating conditions can be associated with lumbosacral radiculopathy. To reinforce the need to have a definitive diagnosis before performing epidural injections in patients with radicular pain who are not responsive to conservative treatment.

SUMMARY OF BACKGROUND DATA

To the authors' knowledge, this is the first reported case of uterine leiomyosarcoma presenting with a lumbosacral radiculopathy.

METHODS

The authors describe the treatment and the radiologic, surgical, and pathologic findings in this patient.

RESULTS

Proper diagnostic work-up led to a diagnosis of metastatic uterine leiomyosarcoma, which was managed with decompressive laminectomy, radiotherapy, and chemotherapy.

CONCLUSIONS

This is the first reported case of a uterine leiomyosarcoma presenting with radicular pain. When a patient has not responded to conservative care, a definitive etiology for radiculopathy needs to be established before epidural steroid injection.

Nerve trunk pain: physical diagnosis and treatment

The management of peripheral neuropathic pain or nerve trunk pain relies upon accurate differential diagnosis. In part neurogenic pain has been attributed to increased activity in, as well as to abnormal processing of non-nociceptive input from, the nervi nervorum. For neurogenic pain to be identified as the dominant feature of a painful condition there should be evidence of increased nerve trunk mechanosensitivity from all aspects of the physical examination procedure. Consistent dysfunction should be identified on key active and passive movements, neural tissue provocation tests as well as nerve trunk palpation. A local cause for the neurogenic pain disorder should also be identified if the condition is to be treated by manual therapy. A treatment approach is presented which has been shown to have efficacy in the relief of pain and restoration of function in cervicobrachial pain disorders where there is evidence according to the outlined examination protocol of nerve trunk pain.

Lateral exit-zone stenosis and lumbar radiculopathy

OBJECT

Hypertrophy of the superior facet of the inferior vertebra, resulting in a compression of the nerve root at the lateral foraminal exit, is a recognized cause of radicular symptoms, particularly in patients in whom previous lumbar spine surgery has failed. The lesion-specific presenting symptoms, imaging findings, and surgical treatment of this lesion, however, have received little attention. The authors prospectively studied a series of eight consecutive patients, in whom a diagnosis of lumbar stenosis at the lateral foraminal exit had been made, to elucidate the common presenting signs and symptoms of this disorder, as well as to evaluate the success of the operative treatment.

METHODS

The eight patients were selected from a group of 250 consecutive patients who presented to a tertiary-care hospital and in whom a diagnosis of long-standing lumbar radiculopathy had been made. In all cases the diagnosis was confirmed by imaging studies and by intraoperative findings. The authors performed decompressive procedures on the nerve root via a medial facet-sparing approach.

CONCLUSIONS

The authors conclude that this lesion presents with characteristic physical findings and on imaging studies that distinguish it from other causes of radiculopathy, and they propose a lesion-specific, facet-sparing surgical technique that has yielded excellent results.

Soft disc herniation in patients with lumbar stenosis

Over a period of 25 years, a surgical technique has evolved for removal of a soft disc herniation in patients with sciatica and lumbar stenosis demonstrated on neuroradiological studies. Initially emphasis was placed on decompression of the entire narrow spinal canal when there was evidence of single nerve root involvement and no history of neurogenic claudication. The author has performed 12 microsurgical discectomies since 1984 and eight percutaneous endoscopic discectomies over the past 6 years that have been successful in relieving radiculitis and radiculopathy in cases of a single herniated nucleus pulposus, even in the presence of a stenotic canal. No patient complained of generalized numbness, weakness, or pain in the lower extremities while walking. After at least 1 year of follow up, the 20 patients who underwent microsurgical or arthroscopic procedures limited to removing the ruptured disc have not required more extensive decompression.

Long-term results of partial undercutting facetectomy for lumbar lateral recess stenosis

STUDY DESIGN

A retrospective review of 57 consecutive patients who had a partial undercutting facetectomy for degenerative lumbar lateral recess stenosis between 1983 and 1988.

OBJECTIVES

To evaluate the long-term results of this procedure.

SUMMARY OF BACKGROUND DATA

Few studies have been published on the long-term outcome of decompression for lumbar stenosis. Most studies have included central as well as lateral recess stenosis and have not differentiated between the two. Furthermore, no study has looked at the long-term results of partial undercutting facetectomy.

METHODS

All patients were assessed by standard questionnaire, clinical examination, and radiography by an independent observer. The minimum follow-up period was 5 years (mean, 8.4 years).

RESULTS

Overall, 72% had no leg pain, 16% had some leg pain needing occasional analgesia, and 12% had severe leg pain needing continual analgesia.

CONCLUSIONS

The long-term results of partial undercutting facetectomy are very satisfying.

The management of chronic spinal pain by blockades: a review

This review of the use of blockades in the diagnosis and symptomatic treatment of spinal pain syndromes is based on increasing knowledge of the innervation of the spine as their rationale. Several clinical syndromes related to the spine are considered. Problems in making a correct diagnosis are discussed. Because of the relative aspecificity of signs and symptoms in spinal pain, a substantial part of the diagnosis may rely on test blockades. The place of test and therapeutic blocks is determined as far as possible. Problems of a pain classification system are discussed. Benefit for the patient depends on the following conditions being achieved: correct diagnosis, careful patient selection, the availability of technical equipment (e.g., fluoroscopy), and a well-designed and well-performed technique in experienced hands.

Caudal epidural blocks for elderly patients with lumbar canal stenosis

OBJECTIVE

To determine the efficacy of caudal epidural blocks (CEB) in relieving pain and the duration of pain relief with CEB in elderly patients suffering from degenerative lumbar canal stenosis (LCS).

DESIGN

This study was a descriptive, prospective study with a 10-month follow-up.

PARTICIPANTS AND SETTING

Thirty patients, 76 +/- 6.7 years of age, with leg discomfort with or without back pain and with LCS documented by magnetic resonance imaging (MRI) within 1 year of the study, were recruited from the outpatient clinic of the Cleveland Clinic Florida. None of the subjects had received CEB or surgery for their leg discomfort and none had relief of pain by analgesics alone.

MEASUREMENTS AND INTERVENTIONS

Subjects received a total of three doses of 0.5% Xylocaine with 80 mg Depo-Medrol into the caudal epidural space through the sacral hiatus at weekly intervals. The Roland 5-point pain rating scale was utilized before and at 2-month intervals up to 10 months after the CEB was administered. MRI was used to identify the degree of LCS.

RESULTS

The degree of LCS on admission was moderate in 66.7% (n = 20) of the patients, mild in 23.3% (n = 7), and severe in the remaining 10% (n = 3). Patients had LCS involving 2.4 +/- 0.49 lumbar vertebrae. The degree of LCS is directly correlated with the pain level before CEB. After CEB, the pain level changed from 3.43 +/- 0.82 to 1.5 +/- 0.86 (P < 0.0000), with a significant relief of pain up to 10 months (the end of observation). The duration of pain relief ranged from 4 to 10 months (P < 0.0001).

CONCLUSION

CEB offers significant pain relief and appears to be a reasonable therapeutic option among elderly patients with LCS. This alternative seems particularly important among patients with poor response to drug therapy and who are either poor surgical risks or who have refused surgery.

The Stiffness of Human Apophyseal Articular Cartilage as an Indicator of Joint Loading

The stiffness and thickness distribution of healthy lumbar apophyseal cartilage was measured in 25 lumbar motion segments (L1–4). The cartilage indentation and needling techniques of Swann and Seedhom (37) were suitably altered to cope with the low modulus and small size of the joint surfaces. A load of 3.12 ± 0.19 N (mean ± s.d.) was applied to the cartilage through a hemispherical indenter of 4.756 mm diameter. The stiffness was calculated using the displacement and instantaneous load 150 ms and 2 s after the indenter first contacted the surface, and using the equations of both Waters (46) and Hayes et al. (47). The mean stiffness of apophyseal joint cartilage was 2.8 M Pa ± 4 per cent (mean ± 95 per cent confidence limit), and thickness 1.02 mm ± 3 per cent. Peripheral apophyseal joint cartilage was softer than central cartilage. The stiffnesses of the centres of the superior and inferior joint surfaces were 3.01 MPa ± 12 per cent and 3.55 MPa ± 11 per cent. Inferior surfaces had a mean thickness of 0.93 mm ± 5 per cent and stiffness of 2.88 MPa ± 7 per cent. Superior surfaces had a mean thickness of 1.10 mm ± 4 per cent and stiffness of 2.74 MPa ± 5 per cent. It was found that the stiffness of cartilage calculated according to the formula of Hayes et al. (47), based on a constitutive analysis of a thin isotropic elastic layer, was directly proportional to both the stiffness calculated using the semi-empirical formula of Waters (46), derived to describe indentation of thin rubber sheets, and the nominal compressive creep modulus calculated by dividing the mean contact stress by the strain at the deepest point of indentation. The creep modulus calculated 2 s after contact was directly proportional to the creep modulus calculated 150 ms after indenter contact, implying that deformation behaviour was uniform between these points despite variation of cartilage stiffness.

A comparative study of the anatomical, radiological and therapeutic features of the lumbar facet joints

An anatomical study of the lumbar apophyseal joints was carried out to facilitate recognition of facet joint lesions, which we now examine routinely by percutaneous arthrography. Special attention was given to the configuration of the different compartments of the joint space and to its relationships with the contents of the intervertebral foramen. The abnormalities seen on lumbar facet joint arthrography are very varied; two major groups should be stressed: synovial fringe hypertrophy and pseudodiverticular synovial ectasia. The percutaneous approach to lumbar facet joint arthrography allows it to be used a therapeutic measure, with injection of anti-inflammatory drugs into the joint space, the beneficial effects of which were confirmed in our series. The precision, efficiency and cost-effectiveness of this outpatient technique justify and should encourage its more widespread application in the diagnosis and treatment of low back pain.

A morphometric study of the lumbar foramen. Influence of flexion-extension movements and of isolated disc collapse

The authors undertook a morphometric study of the intervertebral foramina in anatomic specimens of spines unaffected by degenerative lesions. They studied the variations in shape and size of 38 intervertebral foramina during flexion-extension movements and following an isolated disc collapse. The cast technique takes into account the bony prominences, the bulge of the disc anteriorly and of the capsulo-ligamentous structures posteriorly. In flexion, all the diameters of the foramina are maximal. In full extension all the diameters decrease significantly: the pedicles come closer together, the disc bulges posteriorly and the ligamentum flavum is pushed forward by the superior articular process of the underlying vertebra. A disc collapse of 4 mm decreases all the diameters, and in this case lumbar extension results in a sufficient decrease of foraminal diameter to threaten the nerve root.

Load-bearing role of facets in a lumbar segment under sagittal plane loadings

In the present work, the load-bearing role of the facet joints in a lumbar I2-3 segment is quantitatively determined by means of a three dimensional nonlinear finite element program. The analysis accounts for both material and geometric nonlinearities and treats the facet articulation as a nonlinear moving contact problem. The disc nucleus is considered as an inviscid incompressible fluid and the annulus as a composite of collagenous fibres embedded in a matrix of ground substance. The spinal ligaments are modelled as a collection of nonlinear axial elements. The loadings consist of axial compression and sagittal plane shears and bending moments, acting alone or combined. The results show that in pure compression, the external axial force is transmitted primarily by the intervertebral disc. The facet joints carry only a small percentage of the force. However, the facet joints carry large forces in extension, whereas in small flexion they carry none. Addition of compression tends to increase these contact forces in extension while it has no effect on them in flexion. In extension, the forces on the facet joints are transmitted by both the articular surfaces and the capsular ligaments. Although in small flexion the facets carry no load, large contact forces are predicted to develop as the segment is flexed beyond 7-8 degrees. These forces are of the same magnitude as those computed under large extension rotation and are oriented nearly in the horizontal plane with negligible component in the axial direction. The horizontal components of the contact forces generated during articulation are often larger than the axial components which directly resist the applied compressive force. The axial components of the contact forces, therefore, grossly underestimate the total forces acting on the facets. The transfer of forces from one facet to the adjacent one occurs through distinct areas in flexion and in extension loadings. That is, on the superior articular surface, the contact area shifts from the upper tip in large flexion to the lower margin in extension. On the inferior articular surface, the contact area shifts from the upper and central regions in large flexion to the lower tip in extension.

A finite element study of a lumbar motion segment subjected to pure sagittal plane moments

A nonlinear finite element program has been developed and applied to the analysis of a three-dimensional model of the lumbar L2-3 motion segment subjected to sagittal plane moments. The analysis accounts for both material and geometric nonlinearities and is based on the Updated Lagrangian approach. The disc nucleus has been considered as an incompressible inviscid fluid and the annulus as a composite of collagenous fibres embedded in a matrix of ground substance. Articulation at the facet joints has been treated as a general moving contact problem and the spinal ligaments have been modelled as a collection of nonlinear axial elements. Effects of the loss of intradiscal pressure in flexion and of facetectomy in extension have been analyzed. Comparison of the predicted gross response characteristics with available measurements indicates satisfactory agreement. In flexion relatively large intradiscal pressures are generated, while in extension negative pressures (i.e. suction) of low magnitude are predicted. The stress distribution results indicate that the load transfer path through the posterior elements of the joint in flexion is different from that in extension. In flexion the ligaments are the means of load transfer, while in extension the load is transmitted through the pedicles, laminae and articular processes. In flexion, the inner annulus fibres at the posterolateral location are subject to maximum tensile strain. It is suggested that large flexion moment in combination with other loads is a likely cause of disc prolapse commonly found at this location of the annulus.

Role of stenosis of spinal canal in L4-L5 nerve root compression assessed by flexion-extension myelography

Myelographic flexion-extension studies were performed in four groups of 10 patients each, with (A) normal myelogram; (B) bilateral nerve root compression at L4-L5; (C) unilateral nerve root compression at L4-L5 and (D) nerve root compression at L5-S1. The aim of the investigation was to assess the role of spinal stenosis in contributing to nerve root compression. The results indicate that a form of stenosis of the spinal canal plays an important role in bilateral nerve root compression at L4-L5, and to a lesser extent in unilateral nerve root compression at L4-L5. It does not appear to play a role in L5-S1 nerve root compression (stenosis of the lateral recess left aside). It is advocated that in myelographic L4-L5 nerve root compression additional flexion-extension studies should be performed in order to evaluate the possible role of stenosis of the spinal canal contributing to this compression. Even in nerve root compression by disc extrusion, concomitant spinal stenosis may necessitate additional decompressive laminectomy.

Anatomy of the lumbar radicular canal

The radicular canal is defined as the lateral part of the spinal canal containing the spinal nerve root from its point of emergence through the dural envelope up to and including the intervertebral foramen. The radicular canal, resembling a hollow hemicylinder opened towards the midline, can be divided into three parts, i.e. retrodiscal, parapedicular (the lateral recess per se) and foraminal. The different walls of the canal (notably those of the lateral recess) are described. A review of the main types of roentgenographic exploration of the radicular canal are presented based on these anatomical findings. Finally, this static description of the typical lumbar radicular canal and its variations according to the lumbar or sacral level under consideration is followed by a presentation of the modifications which arise in the upright position and during extension and flexion of the lumbar spine.

High resolution computed tomography in the diagnosis of laterally herniated lumbar discs

Fourteen patients presenting with lumbar radiculopathy had normal or nondiagnostic plain radiographs, myelograms and polytomes of lumbar spine. The high resolution computed axial tomography (HR CAT) demonstrated laterally herniated discs in all cases. The CAT findings correlated well with the clinical presentations and were proven at surgery to be the cause of lumbar nerve entrapment. The preoperative accurate localization of the lesion resulted in complete postoperative relief of lumbar radiculopathy and back pain in 12 cases with two cases, though relieved of the radiculopathy, had residual mild nondisabling low back pain. In cases presenting with sciatica and having nondiagnostic myelograms and other conventional radiological studies, HR CAT of spine is the only reliable radiological test that can be used to rule out laterally herniated lumbar discs.

The straight-leg-raising test: a review*

A positive unilateral straight-leg-raising sign is routinely interpreted as indicative of a "disc lesion. " A review of the literature was undertaken in an attempt to more clearly illustrate the mechanisms and results of the straight-leg-raising test. It was found that a positive straight-leg-raising test has minimal value in differentiating a patient with herniated disc from other patients with love back pain and sciatica. J Orthop Sports Phys Ther 1981;2(3):117-133.

The lateral recess syndrome. A variant of spinal stenosis

Sixteen patients with a surgically proven lateral recess stenosis were studied retrospectively. Lateral recess stenosis should be suspected in patients with disabling intermittent neurogenic claudications. The neurological examination is usually unremarkable. the diagnosis is assured when the lateral recess measures less than 2 mm in height. A lateral recess of 5 mm or more rules out the possibility of a lateral recess stenosis. Surgical decompression of the lateral recess requires removal of the horizontal portion of the superior articular facet.

Zygapophysial arthropathy. Intervertebral apophyseal joint arthropathy

Normal saline injections into appropriate zygapophysial joints were carried out on low back pain suffers to reproduce the pain. Patients were selected on certain defined clinical criteria for inclusion to this pilot study. Only five out of ten patients reported accurate pain reproduction and these were thought to suffer from zygaphophysial arthropathy. It is argued that recognition of this condition will influence its management.

Neurogenic intermittent claudication in association with spondylolisthesis

In the last three decades, more attention has been put upon neurogenic intermittent claudication, also called pseudoclaudication. The syndrome usually develops in patients with congenital narrow spinal canal and secondary additional narrowing. Two cases of spondylolisthesis with neurogenic intermittent claudication are presented. The pathogenesis, symptoms and findings of neurogenic intermittent claudication are discussed.

Overdrainage phenomena in shunt treated hydrocephalus

In addition to the high rate of shunt complications due to obstruction and infection there is a considerable number of undesirable side effects caused by excessive drainage of CSF. Four hundred shunt treated patients are analyzed for overdrainage signs: acute decompression symptoms produced by upward shifting of the brain stem, low pressure headaches (mostly transient), and microcephaly and head deformities like scaphocephaly in infants. Skull X-ray changes reflect adjustment to reduced intracranial content. Slit ventricles and a marked intolerance to minimal pressure rises may be quite troublesome. Subdural haematomas are only exceptionally space-occupying; in most instances they are space-filling. Causes, incidence, management, and prevention are discussed.

Facet "denervation" in the treatment of low back syndrome

Long-term pain relief occurred in 21% of patients with low back and leg pain who underwent injection or radiofrequency rhizotomy. When pain was accompanied by unequivocal limitation of straight leg raising, neither injection nor rhizotomy produced long-term relief. Leg pain improved more than low back pain. Improvement was limited to pain relief as reported to the physician and reduction of medication. There was no improvement in work or activity status. Despite the low success rate, facet "denervation" is uncommonly safe and seems to be of some usefulness in the treatment of patients with low back pain and sciatica.