OBJECTIVE: Caudal epidural steroid injections are used for the symptomatic treatment of radicular lumbosacral pain syndromes, but incorrect injection placement has been recognized as a common problem with the routinely used unguided technique. We aimed to explore the use of sonography to facilitate this procedure. METHODS: In patients with clinically unreliable anatomic landmarks, high-resolution real-time sonography was used to identify those landmarks and to assist in correct needle placement. RESULTS: Sonography enabled localization of the sacral hiatus landmarks. We found this method particularly useful for guiding needle placement in patients with moderate obesity. CONCLUSIONS: Real-time sonography can facilitate caudal epidural steroid injections. (+info)
Conjoined lumbosacral nerve roots: current aspects of diagnosis.
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Conjoined lumbosacral nerve roots (CLNR) are the most common anomalies involving the lumbar nerve structures which can be one of the origins of failed back syndromes. They can cause sciatica even without the presence of a additional compressive impingement (such as disc herniation, spondylolisthesis or lateral recess stenosis), and often congenital lumbosacral spine anomalies (such as bony defects) are present at the "conjoined sheaths". This congenital anomaly has been reported in 14% of cadaver studies, but myelographic or computed tomographic studies have revealed an incidence of approximately 4% only. Diagnostic methods such as magnetic resonance imaging (MRI) are helpful for determination of the exact anatomical relations in this context. We present five typical cases of conjoined nerve roots observed during a 1 year period, equivalent to 6% of our out-patients without a history of surgical treatment on the lumbar spine. In all cases with suspicious radiological findings MRI or lumbar myelography combined with CT and multiplanar reconstructions is recommended. (+info)
Correlation of nerve root pain with dermatomal sensory threshold and back pain with spinal movement in single level lumbar spondylosis.
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We studied 27 patients with low back pain and unilateral L5 or S1 spinal nerve root pain. Significant radiological changes were restricted to the symptomatic root level, when compared with controls. Low back and leg pain were graded on a visual analogue scale. Dermatomal quantitative sensory tests revealed significant elevations of warm, cool and touch perception thresholds in the affected dermatome, compared with controls. These elevations correlated with root pain (warm v L5 root pain; r = 0.88, p < 0.0001), but not with back pain. Low back pain correlated with restriction of anteroposterior spinal flexion (p = 0.02), but not with leg pain. A subset of 16 patients underwent decompressive surgery with improvement of pain scores, sensory thresholds and spinal mobility. A further 14 patients with back pain, multilevel nerve root symptoms and radiological changes were also studied. The only correlation found was of low back pain with spinal movement (p < 0.002). We conclude that, in patients with single level disease, dermatomal sensory threshold elevation and restriction of spinal movement are independent correlates of sciatica and low back pain. (+info)
A malignant peripheral nerve-sheath tumour responding to chemotherapy.
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A malignant peripheral nerve-sheath tumour developed in the right S1 nerve root in a man aged 30 causing back pain and sciatica. CT and MRI revealed a destructive tumour of the sacrum invading the retroperitoneal space. The tumour was not resectable with an adequate margin. Chemotherapy, consisting of high-dose ifosfamide followed by a combination of vincristine, doxorubicin and cyclophosphamide, was given with success. Malignant peripheral nerve-sheath tumours are thought to respond weakly to chemotherapy, but the response in our patient was complete. (+info)
Efficacy of etanercept in the treatment of acute, severe sciatica: a pilot study.
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OBJECTIVES: To explore the efficacy of a tumour necrosis factor alpha (TNFalpha) inhibitor (etanercept, Enbrel) in patients with severe sciatica. METHODS: A pilot study of etanercept was conducted in patients admitted to hospital for acute severe sciatica. Ten consecutive patients received three subcutaneous injections of etanercept (25 mg every 3 days) in addition to standard analgesia. Response was evaluated at day 10 (T1) and week 6 (T2) using a visual analogue scale for leg pain (VASL) and for low back pain (VASB), and two validated functional scores: the Oswestry disability index (ODI) and the Roland Morris disability questionnaire (RMDQ). The control group consisted of 10 patients with severe sciatica, who took part in an observational study on i.v. methylprednisolone. RESULTS: In the etanercept group all variables improved: VASB from 36 to 7; VASL from 74 to 12; RMDQ from 17.8 to 5.8, and ODI from 75.4 to 17.3; all p<0.001. Pain (VASL and VASB: p<0.001) and ODI (p<0.05) were significantly better in the etanercept group than in the methylprednisolone group. CONCLUSION: In this open, historical group controlled study, patients with severe sciatica had sustained improvement after a short treatment with etanercept that was better than standard care plus a short course of methylprednisolone. These results suggest that inhibition of TNFalpha is beneficial in the treatment of sciatica and support a pathological role for TNFalpha in the pathogenesis of sciatica. These results need to be confirmed by a randomised controlled trial. (+info)
Neurosurgeons' management of lumbosacral radicular syndrome evaluated against a clinical guideline.
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To establish to what extent neurosurgeons subscribe to the lumbosacral radicular syndrome (LRS) guideline, and to evaluate their current management of patients with LRS against the guideline. All active neurosurgeons in the Netherlands (n=92) were mailed a questionnaire about the guideline and data from 66 responders were analysed. Patients were recruited via seven of the participating neurosurgeons and were interviewed once by telephone. The medical records of the participating patients (n=163) were also examined. Of the 26 propositions in the LRS guideline, seven were not fully endorsed by the neurosurgeons. Three of these seven propositions may need updating based on "new evidence". The time between the onset of the LRS episode and the actual moment of surgery was considerably longer than that recommended in the guideline. Based on their current management of LRS patients, the neurosurgeons largely adhere with the LRS guideline. (+info)
Piriformis pyomyositis: a rare cause of sciatica.
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A 30-year-old Thai woman with piriformis pyomyositis presented with sciatica. Computed tomography showed swelling and enhancement of the right gluteus medius and piriformis muscles. She made a complete recovery after a course of intravenous antibiotics. This condition has only been reported three other times and is often diagnosed with difficulty. It could be erroneously dismissed as a lumbar disc prolapse. If untreated, it could lead to prolonged hospital stay and death. A high index of suspicion, early diagnosis and appropriate antibiotic or surgical treatment leads to full recovery. (+info)
Predictive value of the duration of sciatica for lumbar discectomy. A prospective cohort study.
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The optimum timing of lumbar discectomy for sciatica is imprecise. We have investigated a number of prognostic factors in relation to the outcome of radiculopathy after lumbar discectomy. We recruited 113 consecutive patients of whom 103 (91%) were followed up at one year. We found a significant association between the duration of radiculopathy and the changes in the Oswestry Disability Index score (p = 0.005) and the low back outcome score (p = 0.03). Improvement in pain was independent of all variables. Patients with an uncontained herniated disc had a shorter duration of symptoms and a better functional outcome than those with a contained herniation. Our study suggests that patients with sciatica for more than 12 months have a less favourable outcome. We detected no variation in the results for patients operated on in whom the duration of sciatica was less than 12 months. (+info)