[Reflex sympathetic dystrophy secondary to piriformis syndrome: a case report.]

Agri. 2009 Apr; 21(2): 75-79Akçalı D, Taş A, Cizmeci P, Oktar S, Zinnuroğlu M, Arslan E, Köseoğlu H, Babacan APiriformis syndrome is a rare cause of hip and foot pain which may be due to sciatic nerve irritation because of anatomic abnormalities of sciatic nerve and piriformis muscle or herniated disc, facet syndrome, trochanteric bursit, sacroiliac joint dysfunction, endometriosis and other conditions where sciatic nerve is irritated. There has been no reflex sympathetic dystrophy (RSD) case presented due to piriformis syndrome before. A sixty-two-year-old female patient had right foot and hip pain (VNS: 8), redness and swelling in the foot since 15 days. Her history revealed long walks and travelling 3 weeks ago and sitting on the foot for a long time for a couple of days. Physical examination revealed painful hip movement, positive straight leg rise. Erythema and hyperalgesia was present in dorsum of the right foot. Right foot dorsiflexion was weak and hyperesthesia was found in right L4-5 dermatome. Medical treatment and ultrasound treatment to piriformis muscle was not effective. The patient was injected 40 mg triamcinolon and local anesthetic in right piriformis muscle under floroscopy by diagnosis of piriformis syndrome, neuropathic pain and RSD. Pain and hyperalgesia resolved and motor weakness was better. During follow-up right foot redness resolved and pain decreased (VNS: 1). In this case report, there was vascular, muscle and skeletal signs supporting RSD, which shows us the therapoetic effect of diagnostic piriformis injection. The patient history, physical examination and diagnostic tests were evaluated by a multidisciplinary team which contributed to the treatment.

Systematic review of percutaneous lumbar mechanical disc decompression utilizing Dekompressor.

Pain Physician. 2009 May-Jun; 12(3): 589-99Singh V, Benyamin RM, Datta S, Falco FJ, Helm S, Manchikanti LBACKGROUND: In recent years, a number of minimally invasive nuclear decompression techniques for lumbar disc prolapse, protrusion, and/or herniation have been introduced, including the Dekompressor a device utilizing an Archimedes screw. The primary goal of the surgical treatment of nerve root compression from a disc protrusion continues to be the relief of compression by removing the herniated nuclear material with open discectomy. However, poor results have been reported for contained disc herniations with open surgical interventions. The results with several alternative techniques including the Dekompressor, automated percutaneous discectomy, and laser discectomy have been described, but are not convincing. There is a paucity of evidence for all decompression techniques. STUDY DESIGN: A systematic review of the mechanical disc decompression with Dekompressor literature. OBJECTIVE: The objective of this systematic review is to evaluate the clinical effectiveness of the Dekompressor, a high rotation per minute device utilizing an Archimedes screw, used in mechanical lumbar disc decompression. METHODS: The literature search was conducted utilizing a comprehensive strategy for mechanical disc decompression utilizing the Dekompressor. A literature search was conducted using only English language literature in a comprehensive search of databases including PubMed, EMBASE, the Cochrane Library, along with systematic reviews, and cross-references from reviews, systematic reviews, and individual articles. The quality of the manuscripts included was evaluated according to Cochrane review criteria for randomized controlled trials (RCTs), and for observational studies with the criteria developed by the Agency for Healthcare Research and Quality (AHRQ). The level of evidence developed by the United States Preventive Services Task Force (USPSTF) was utilized in this review. The evidence was classified as Level I, II, or III with 3 subcategories in Level II for a total of 5 levels of evidence. OUTCOME MEASURES: Pain relief was the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, opioid intake, and return to work. Short-term effectiveness was defined as one year or less, whereas, long-term effectiveness was defined as greater than one year. RESULTS: Based on USPSTF criteria the indicated level of evidence for the mechanical high RPM device or Dekompressor is Level III for short- and long-term relief. LIMITATIONS: Lack of literature, both randomized and observational. CONCLUSION: This systematic review illustrates Level III evidence for mechanical percutaneous disc decompression procedures with the high RPM device or Dekompressor.

[Observation on therapeutic effect of moxibustion on temperature-sensitive points for lumbar disc herniation]

Zhongguo Zhen Jiu. 2009 May; 29(5): 382-4Tang FY, Huang CJ, Chen RX, Xu M, Liu BX, Liang ZOBJECTIVE: To compare therapeutic effects of traditional moxibustion and moxibustion on temperature-sensitive points for lumbar disc herniation. METHODS: One hundred and twenty cases were randomly divided into a temperature-sensitive point group and a traditional moxibustion group, 60 cases in each group. The temperature-sensitive point group was treated with moxibustion on the temperature-sensitive points in the temperature-sensitive high incidence area such as waist and lower limbs, once each day; the traditional moxibustion group was treated with warming moxibustion at Jiaji (EX-B 2), Ciliao (BL 32), Zhibian (BL 54), Huantiao (GB 30), Weizhong (BL 40), Yanglingquan (GB 34), Kunlun (BI. 60), once each day, 7 days constituting one course. The therapeutic effect and the recurrence rate were observed after one course treatment and six months later. RESULTS: After treatment for one course, the cured-markedly effective rate was 65.00% in the temperature-sensitive point group, superior to 50.0% in the traditional moxibustion group, with a significant difference between the two groups (P < 0.05); all effective cases were followed-up for six months, the cured-markedly effective rate and the recurrence rate were 62.3% and 26.4% in the temperature-sensitive point group, and 34.2% and 46.3% in the traditional moxibustion group, the therapeutic effect of the temperature-sensitive point group being superior to the traditional moxibustion group, and the recurrence rate was lower than the traditional moxibustion group (both P < 0.05). CONCLUSION: Moxibustion on temperature-sensitive points is a effective therapy for lumbar disc herniation, with stable therapeutic effect and low recurrence rate.

[Neurological complication after a vertical infraclavicular brachial plexus block : Case report of possible differential diagnoses of a neurological deficit.]

Anaesthesist. 2009 Jun 24; Ehrenberg R, Bucher M, Graf BA 72-year-old man with an obliteration of the brachial artery received a vertical infraclavicular block (VIP) for vascular surgery but 20 h after the operation a complete paresis of the affected extremity occurred. A new vascular obliteration could be excluded. During the diagnostic examination the patient noticed a snapping noise in the cervical column when moving his head and an abrupt recovery of the neurological deficits occurred. The radiological diagnostic provided no indication of cerebral ischemia or lesions of the brachial plexus. An additional diagnostic finding was a profound herniated vertebral disc with compression of the myelon. Fortunately, the neurological deficits completely returned to normal.

When is the appropriate time for surgical intervention of the herniated lumbar disc in the adolescent?

J Clin Neurosci. 2009 Jun 20; Fakouri B, Nnadi C, Boszczyk B, Kunsky A, Cacciola FSymptomatic lumbar disc herniation in the adolescent is uncommon. The appropriate treatment in this particular age group is not clear. We conducted a retrospective review of the medical, surgical, and radiological records of six adolescents with symptomatic lumbar disc herniation who underwent microdiscectomy after failed conservative therapy. The mean follow-up was 13months. All patients improved quickly and returned to their normal activity levels. We suggest that severe pain resulting from a herniated lumbar disc, even without any neurological deficit, is an indication for microdiscectomy in adolescents so that these patients return to full-time education and normal activities as soon as possible.

The use of flexion-extension magnetic resonance imaging for evaluating signal intensity changes of the cervical spinal cord.

J Neurosurg Spine. 2009 Apr; 10(4): 366-73Guppy KH, Hawk M, Chakrabarti I, Banerjee AThe authors present 2 cases involving patients who presented with myelopathy. Magnetic resonance imaging of the cervical spine showed spinal cord signal changes on T2-weighted images without any spinal cord compression. Flexion-extension plain radiographs of the spine showed no instability. Dynamic MR imaging of the cervical spine, however, showed spinal cord compression on extension. Compression of the spinal cord was caused by dynamic anulus bulging and ligamentum flavum buckling. This report emphasizes the need for dynamic MR imaging of the cervical spine for evaluating spinal cord changes on neutral position MR imaging before further workup for other causes such as demyelinating disease.

Senescence mechanisms of nucleus pulposus chondrocytes in human intervertebral discs.

Spine J. 2009 Jun 18; Kim KW, Chung HN, Ha KY, Lee JS, Kim YYBACKGROUND CONTEXT: The population of senescent disc cells has been shown to increase in degenerated or herniated discs. However, the mechanism and signaling pathway involved in the senescence of nucleus pulposus (NP) chondrocytes are unknown. PURPOSE: To demonstrate the mechanisms involved in the senescence of NP chondrocytes. STUDY DESIGN/SETTING: Senescence-related markers were assessed in the surgically obtained human NP specimens. PATIENT SAMPLE: NP specimens remaining in the central region of the intervertebral disc were obtained from 25 patients (mean: 49 years, range: 20-75 years) undergoing discectomy. Based on the preoperative magnetic resonance images, there were 3 patients with Grade II degeneration, 17 patients with Grade III degeneration, and 5 patients with Grade IV degeneration. OUTCOME MEASURES: We examined cell senescence markers (senescence-associated beta-galactosidase [SA-beta-gal], telomere length, telomerase activity, p53, p21, pRB, and p16) and the hydrogen peroxide (H(2)O(2)) content as a marker for an oxidative stress in the human NP specimens. METHODS: SA-beta-gal expression, telomere length, telomerase activity, and H(2)O(2) content as well as their relationships with age and degeneration grades were analyzed. For the mechanism involved in the senescence of NP chondrocytes, expressions of p53, p21, pRB, and p16 in these cells were assessed with immunohistochemistry and Western blotting. RESULTS: The percentages of SA-beta-gal-positive NP chondrocytes increased with age (r=.82, p

The posterior cervical foraminotomy in the treatment of cervical disc/osteophyte disease: a single-surgeon experience with a minimum of 5 years' clinical and radiographic follow-up.

J Neurosurg Spine. 2009 Apr; 10(4): 347-56Jagannathan J, Sherman JH, Szabo T, Shaffrey CI, Jane JAOBJECT: This study details long-term clinical and radiographic outcomes following single-level posterior cervical foraminotomy for degenerative disc or osteophyte disease. METHODS: The authors conducted a retrospective review of 162 cases involving patients treated by a single surgeon using a posterior cervical foraminotomy. Inclusion criteria were a minimum of 5 years' clinical and radiographic follow-up and unilateral single-level posterior cervical foraminotomy for degenerative disease between C-3 and C-7. Patients who had undergone previous operations, those who underwent bilateral procedures, and those who underwent foraminotomy as part of a larger laminectomy were excluded. The Neck Disability Index (NDI) was used for clinical follow-up, and radiographic follow-up was performed using static and dynamic lateral radiographs to compare focal and segmental alignment and changes in disc-space height. RESULTS: The mean presenting NDI score was 18 (range 2-39). The most common presenting symptoms were radiculopathy (110 patients [68%]), neck pain (85 patients [52%]), and subjective weakness (91 patients [56%]). The mean preoperative focal angulation at the surgically treated level was 4.2 degrees (median 4.1 degrees , range 7.3-15.3 degrees ), and the mean preoperative segmental curvature between C-2 and C-7 was 18.0 degrees (median 19.3 degrees , range -22.1 to 39.3 degrees ). The mean postoperative NDI score was 8 (range 0-39). Improvement in NDI scores was seen in 150 patients (93%). Resolution of radiculopathy was experienced by 104 patients (95% of patients with radiculopathy). The mean radiographic follow-up was 77.3 months (range 60-177 months). No statistically significant changes in focal or segmental kyphosis or disc-space height were seen among the overall cohort with time (Cox proportional hazards analysis and Student t-test, p > 0.05). The mean postoperative focal angulation was 4.1 degrees (median 3.9 degrees , range -9.9 degrees to 15.1 degrees ) and mean postoperative segmental angulation was 17.6 degrees (median 15.4 degrees , range -40.2 to 35.3 degrees ). Postoperative instability on dynamic imaging was present in 8 patients (4.9%); 7 of these patients were clinically asymptomatic and were treated conservatively, and 1 required cervical fusion. Postoperative loss of lordosis (defined as segmental Cobb angle < 10 degrees ) was seen in 30 patients (20%), 9 of whom had clinical symptoms and 4 of whom required further surgical correction. Factors associated with worsening sagittal alignment (Cox proportional hazards analysis, p < 0.05) included age > 60 at initial surgery, the presence of preoperative cervical lordosis of < 10 degrees , and the need for posterior surgery after the initial foraminotomy. CONCLUSIONS: The posterior cervical foraminotomy is highly effective in treating patients with cervical radiculopathy and results in long-lasting pain relief and improved quality-of-life outcomes in most patients. Long-term radiographic follow-up shows no significant trend toward kyphosis, although select patient subsets (patients older than 60 years, patients who had previous posterior surgery, and patients with < 10 degrees of lordosis preoperatively) appear to be at higher risk and require closer follow-up.

Prostaglandin E1 and misoprostol increase epidermal growth factor production in 3D-cultured human annulus cells.

Spine J. 2009 Jun 15; Gruber HE, Hoelscher G, Loeffler B, Chow Y, Ingram JA, Halligan W, Hanley ENBACKGROUND CONTEXT: Epidermal growth factor (EGF) is a peptide known to modulate a number of cellular responses including embryogenesis, cell proliferation, and cell survival. Little is known about EGF and its regulation in human annulus cells. Previous work has identified EGF and its receptor in control outer annulus disc tissue, but not in herniated tissue. PURPOSE: To determine if human annulus cells express EGF in vitro, to determine if the epidermal growth factor-receptor (EGF-r) was expressed in vivo and in vitro in disc cells, to test the effect of EGF on annulus cell proliferation and proteoglycan production in vitro, and to test the effect of prostaglandin E1 (PGE1) and misoprostol on disc cell production of EGF in vitro. STUDY DESIGN/SETTING: Studies were approved by the authors' Human Subjects Institutional review Board. Human disc tissue was used for immunocytochemistry, and human annulus cells were tested in vitro. PATIENT SAMPLE: Thirty-four disc specimens were used for studies of proteoglycan production, cell proliferation, and EGF production in vitro. An additional nine discs were used for EGF-r immunolocalization. METHODS: Disc tissue was used for immunocytochemical studies for the localization of EGF-r and as a source for cultured annulus cells. Monolayer culture was used to test proliferation responses to 0, 25, 50, or 75ng/mL EGF over a 2-day culture period. Three-dimensional (3D) culture in a collagen sponge was used to test 100,000 cells cultured in a paired experimental design over 14 days for production of EGF and proteoglycans. Cells were exposed to control conditions, or to either misoprostol at 8ng/mL or PGE1 at 10(-7)M. Conditioned media was harvested and assayed using an enzyme-linked immunosorbent assay (ELISA) assay with the Human Protein Cytokine Antibody Array I kit. Replicate EGF relative intensity values were averaged and normalized to controls assayed on the same membrane. 3D-cultured cells were also used to confirm EGF gene expression using microarray analysis. Standard statistical methods were used to analyze results. RESULTS: Microarray analysis of mRNA from annulus cells in 3D culture confirmed expression of EGF, and immunocytochemistry verified the presence of EGF-r in vitro and in vivo. PGE1, at a dose of 10(-7)M, and misoprostol (a synthetic PGE1 analog) at a dose of 8ng/mL, both significantly increased EGF levels in annulus cells cultured in 3D compared with control levels (p=.031 and .034, respectively). No significant difference, however, was seen in cell proliferation or in total sulfated proteoglycan production in EGF-exposed annulus cells. CONCLUSIONS: Data showed that EGF is expressed and produced by annulus cells in vivo and in 3D culture, with significantly greater in vitro EGF produced in the presence of PGE1 or the PGE1 analog misoprostol. Misoprostol, developed for prevention/treatment of nonsteroidal anti-inflammatory-induced gastropathy, has now been reported to have some interesting anabolic effects stimulating osteoblasts during fracture healing and during ovariectomy in animal models. Exogenous EGF did not increase cell proliferation in monolayer, or total production of proteoglycans in 3D culture. Additional work is needed to further delineate the role of EGF in the human disc.

[Nerve root compression by gas containing lumbar disc herniation--case report]

Brain Nerve. 2009 Jun; 61(6): 691-4Yasuoka H, Nemoto O, Kawaguchi M, Naitou S, Yamamoto K, Ukegawa YThe radiographic appearance of gas collection in the intervertebral disc represents the so-called "vacuum phenomenon." Incidence of the vacuum phenomenon on plain radiographs is reported to be 1-20%, whereas gas-containing disc herniations are rarely observed. We present a case report involving a patient with L4/5 gas-containing disc herniation, which was demonstrated by CT and MRI scans and was also surgically documented. A 48-year-old man with no previous back trauma presented with a 14-day history of left leg pain. On neurologic examination, the straight leg raising test was positive at 60degrees. Leg muscle strength was weak on the extensor hallucis longus. Sensory disturbances and abnormalities in deep-tendon reflexes were not observed. Lumbar roentogenograms showed "vacuum phenomenon" at L2/3, L4/5 and the L5/S disc space. MRI indicated a herniated disc at L4/5 displacing the dural sac and a focal low intensity in the lesion. Administration of an epidural block relieved the patient's symptoms. Ten months later, the patient reported a gradual return of similar left leg pain. His symptoms did not respond to conservative management. Lumbar spine films indicated abnormalities identical to the original results. MRI showed an enlarged area of low intensity with compression of the left L5 nerve root. In addition to recurrent pain, discography with metrizamide injections confirmed the presence of intradiscal gas and compression of the left L5 nerve root. During surgery, a gray-bluish air mass compressing the L5 nerve root was identified. Manipulation of the mass resulted in rupture and the release of gas. The displaced nerve root immediately relaxed to its normal position. Seven months after the operation, the patient remains free of pain.

Cervical disc herniation producing acute brown-sequard syndrome.

J Korean Neurosurg Soc. 2009 May; 45(5): 312-4Kim JT, Bong HJ, Chung DS, Park YSBrown-Sequard syndrome may be the result of penetrating injury to the spine, but many other etiologies have been described. This syndrome is most commonly seen with spinal trauma and extramedullary spinal neoplasm. A herniated cervical disc has been rarely reported as a cause of this syndrome. We present a case of a 28-year-old male patient diagnosed as large C3-C4 disc herniation with spinal cord compression. He presented with left hemiparesis and diminished sensation to pain and temperature in the right side below the C4 dermatome. Microdiscectomy and anterior cervical fusion with carbon fiber cage containing a core of granulated coralline hydroxyapatite was performed. After the surgery, rapid improvement of the neurologic deficits was noticed. We present a case of cervical disc herniation producing acute Brown-Sequard syndrome with review of pertinent literature.

Herniated nucleus pulposus in isthmic spondylolisthesis: higher incidence of foraminal and extraforaminal types.

Acta Neurochir (Wien). 2009 Jun 5; Kim KS, Chin DK, Park JYBACKGROUND: The purpose of this study was to evaluate the pattern of disc herniation and to investigate the associated symptoms in cases of isthmic spondylolisthesis. It is well known that the pathogenesis of degenerative spondylolisthesis associates with disc degeneration, followed by facet laxity and ligamentum flavum hypertrophy, which result in severe spinal canal stenosis. But isthmic spondylolisthesis is known to have a different pathogenesis. In isthmic spondylolisthesis, pseudodisc bulging is easily identified, and canal stenosis is comparatively rare. Therefore, we propose that isthmic spondylolisthesis has a different pattern of disc herniation from degenerative spondylolisthesis. We studied the type, incidence of disc herniation and clinical symptoms related to isthmic spondylolisthesis. METHOD: This study included 132 patients with isthmic spondylolisthesis who had undergone an operation in the last 4 years. Among them, 120 patients were retrospectively reviewed. The mean age was 49.6 years, and the sex ratio was 1 to 1.93 (male to female). The disc herniation type was identified according to the classification of Bonneville. FINDINGS: There were 78 patients (65%) with L4 to L5 spondylolisthesis and 42 patients (35%) with L5 to S1 spondylolisthesis. Eighty-two patients (68.3%) had only pseudodisc bulging without disc herniation, and 38 patients (31.7%) had pseudodisc bulging with disc herniation. Among the 38 patients with disc herniation, there were: medial type: 1 patient (2.6%), medial + posterolateral type: 1 patient (2.6%), posterolateral + foraminal type: 2 patients (5.3%), foraminal type: 7 patients (18.4%), foraminal + extraforaminal type: 25 patients (65.8%) and extraforaminal type: 2 patients (5.8%). Overall extreme lateral disc herniation (foraminal, extraforaminal) was seen in 36 patients, which was 30% of the total isthmic spondylolisthesis cases. In 26 out of 36 patients (72.2%), the dermatome was matched to the exact location of the extreme lateral disc herniation. In all cases, the extreme lateral disc herniation migrated upward slightly, about one slice (2 mm) according to thin-cut CT. CONSCLUSIONS: As expected, pseudodisc bulging without disc herniation was the most common type in isthmic spondylolisthesis. However, in cases of disc herniation, extreme lateral disc herniation occasionally occurs; therefore, every isthmic spondylolisthesis patient should be examined carefully for extreme lateral disc herniation with thin-cut axial CT or MRI, especially when the patients complain of lateralizing symptom.