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1.  Dorsal spinal epidural cavernous hemangioma 
A 61-year-old female patient presented with diffuse pain in the dorsal region of the back of 3 months duration. The magnetic resonance imaging showed an extramedullary, extradural space occupative lesion on the right side of the spinal canal from D5 to D7 vertebral levels. The mass was well marginated and there was no bone involvement. Compression of the adjacent thecal sac was observed, with displacement to the left side. Radiological differential diagnosis included nerve sheath tumor and meningioma. The patient underwent D6 hemilaminectomy under general anesthesia. Intraoperatively, the tumor was purely extradural in location with mild extension into the right foramina. No attachment to the nerves or dura was found. Total excision of the extradural compressing mass was possible as there were preserved planes all around. Histopathology revealed cavernous hemangioma. As illustrated in our case, purely epidural hemangiomas, although uncommon, ought to be considered in the differential diagnosis of spinal epidural soft tissue masses. Findings that may help to differentiate this lesion from the ubiquitous disk prolapse, more common meningiomas and nerve sheath tumors are its ovoid shape, uniform T2 hyperintense signal and lack of anatomic connection with the neighboring intervertebral disk or the exiting nerve root. Entirely extradural lesions with no bone involvement are rare and represent about 12% of all intraspinal hemangiomas.
doi:10.4103/0974-8237.77677
PMCID: PMC3075829  PMID: 21572634
Epidural; hemangioma; spinal
2.  Lumbar discal cyst causing bilateral radiculopathy 
Background:
Discal cyst is a rare lesion that can result in clinical symptoms typical of disc herniation manifesting as a unilateral single nerve root lesion. To the best of the authors’ knowledge, this is the first reported case of discal cyst resulting in bilateral radiculopathy.
Case Description:
A 48-year-old female presented with bilateral sciatica and neurogenic claudication for 3 months. Magnetic resonance imaging revealed an extradural cystic lesion compressing the ventral aspect of the thecal sac at the level of the L3-L4 intervertebral disc. The lesion showed low and high signal intensities on T1- and T2-weighted images, respectively. Total excision of the cyst was achieved after a left hemipartial laminectomy of L3, and an obvious communication with the disc space was found. Bilateral sciatica was immediately resolved after surgery, and was sustained at the two-year follow-up. The histological diagnosis was consistent with a discal cyst.
Conclusions:
Although a discal cyst is extremely rare, the possibility of a discal cyst should be considered in differential diagnosis of patients with radiculopathy, particularly when encountering any extradural mass lesion ventral to the thecal sac. Surgical resection is the most employed therapeutic method for symptomatic lumbar discal cysts.
doi:10.4103/2152-7806.77026
PMCID: PMC3050063  PMID: 21427789
Bilateral; discal cyst; lumbar spinal stenosis; radiculopathy
3.  Use of a multimodal conservative management protocol for the treatment of a patient with cervical radiculopathy 
Objective
The purpose of this study is to describe and discuss the treatment of a cervical disk herniation using a sequential multimodal conservative management approach.
Clinical Features
A 40-year-old man had complaints of headache and severe sharp neck pain radiating to his left shoulder down to his arm, forearm, and hand. Results of electromyography/nerve conduction studies were abnormal. Magnetic resonance imaging revealed a large disk protrusion at C5-C6 with indentation of the thecal sac and a spur at the posterior margin. Moderate left neural foraminal narrowing was present at C5-C6 with narrowed intervertebral disk space at C5-C6 and C6-C7.
Intervention and Outcome
High-velocity, low-amplitude chiropractic manipulation; electrotherapy; ice; and exercise were used for treatment. The Neck Disability Index was used as a primary and electromyography/nerve conduction studies as a secondary outcome measurement. Based on the Neck Disability Index, there was an overall 89.65% symptoms improvement from the baseline.
Conclusions
This case study demonstrated possible beneficial effects of the multimodal treatment approach in a patient with cervical radiculopathy.
doi:10.1016/j.jcm.2010.05.004
PMCID: PMC3110408  PMID: 22027207
Chiropractic; Cervical vertebrae; Cryotherapy; Intervertebral disk displacement; Manipulation, spinal; Radiculopathy; Rehabilitation
4.  A Prospective, Observational Study of the Relationship Between Body Mass Index and Depth of the Epidural Space During Lumbar Transforaminal Epidural Steroid Injection 
Background and Objectives
Previous studies have concluded that transforaminal epidural steroid injections (ESIs) are more effective than interlaminar injections in the treatment of radiculopathies due to lumbar intervertebral disk herniation. There are no published studies examining the depth of epidural space using a transforaminal approach. We investigated the relationship between body mass index (BMI) and the depth of the epidural space during lumbar transforaminal ESIs.
Methods
Eighty-six consecutive patients undergoing lumbar transforaminal ESI at the L3-L4, L4-L5, and L5-S1 levels were studied. Using standard protocol, the foraminal epidural space was attained using fluoroscopic guidance. The measured distance from needle tip to skin was recorded (depth to foraminal epidural space). The differences in the needle depth and BMI were analyzed using regression analysis.
Results
Needle depth was positively associated with BMI (regression coefficient [RC], 1.13; P < 0.001). The median depths (in centimeters) to the epidural space were 6.3, 7.5, 8.4, 10.0, 10.4, and 12.2 for underweight, normal, preobese, obese I, obese II, and obese III classifications, respectively. Sex (RC, 1.3; P = 0.02) and race (RC, 0.8; P = 0.04) were also significantly associated with needle depth; however, neither factor remained significant when BMI was accounted as a covariate in the regression model. Age, intervertebral level treated, and oblique angle had no predictive value on foraminal depth (P > 0.2).
Conclusion
There is a positive association between BMI and transforaminal epidural depth, but not with age, sex, race, oblique angle, or intervertebral level.
doi:10.1097/AAP.0b013e31819a12ba
PMCID: PMC2715548  PMID: 19282707
5.  Cauda Equina Syndrome Caused by Pseudogout Involving the Lumbar Intervertebral Disc 
Journal of Korean Medical Science  2012;27(12):1591-1594.
Calcium pyrophosphate dihydrate (CPPD) deposition disease, also known as pseudogout, is a disease that causes inflammatory arthropathy in peripheral joints, however, symptomatic involvement of the intervertebral disc is uncommon. Herein, we describe a 59-yr-old patient who presented with cauda equina syndrome. Magnetic resonance imaging of the patient showed an epidural mass-like lesion at the disc space of L4-L5, which was compressing the thecal sac. Biopsy of the intervertebral disc and epidural mass-like lesion was determined to be CPPD deposits. We reviewed previously reported cases of pseudogout involving the lumbar intervertebral disc and discuss the pathogenesis and treatment of the disease.
doi:10.3346/jkms.2012.27.12.1591
PMCID: PMC3524444  PMID: 23255864
Calcium Pyrophosphate Dehydrate (CPPD); Pseudogout; Lumbar Spine; Intervertebral Disc
6.  Conservative management of recurrent lumbar disk herniation with epidural fibrosis: a case report 
Journal of Chiropractic Medicine  2012;11(4):249-253.
Objective
A retrospective case report of a 24-year-old man with recurrent lumbar disk herniation and epidural fibrosis is presented. Recurrent lumbar disk herniation and epidural fibrosis are common complications following lumbar diskectomy.
Clinical Features
A 24-year-old patient had a history of lumbar diskectomy and new onset of low back pain and radiculopathy. Magnetic resonance imaging revealed recurrent herniation at L5/S1, left nerve root displacement, and epidural fibrosis.
Intervention and Outcomes
The patient received a course of chiropractic care including lumbar spinal manipulation and rehabilitation exercises with documented subjective and objective functional and symptomatic improvement.
Conclusion
This case report describes chiropractic management including spinal manipulative therapy and rehabilitation exercises and subsequent objective and subjective functional and symptomatic improvement.
doi:10.1016/j.jcm.2012.10.002
PMCID: PMC3706706  PMID: 23843756
Low back pain; Recurrent; Disk displacement; Intervertebral; Chiropractic manipulation; Diskectomy
7.  Dorsal Extradural Lumbar Disc Herniation Causing Cauda Equina Syndrome : A Case Report and Review of Literature 
A 73-year-old male presented with a rare dorsally sequestrated lumbar disc herniation manifesting as severe radiating pain in both leg, progressively worsening weakness in both lower extremities, and urinary incontinence, suggesting cauda equina syndrome. Magnetic resonance imaging suggested the sequestrated disc fragment located in the extradural space at the L4-L5 level had surrounded and compressed the dural sac from the lateral to dorsal sides. A bilateral decompressive laminectomy was performed under an operating microscope. A large extruded disc was found to have migrated from the ventral aspect, around the thecal sac, and into the dorsal aspect, which compressed the sac to the right. After removal of the disc fragment, his sciatica was relieved and the patient felt strength of lower extremity improved.
doi:10.3340/jkns.2010.47.3.217
PMCID: PMC2851086  PMID: 20379476
Lumbar disc herniation; Dorsal; Intradural; Migrated
8.  Intradural Migration of a Sequestrated Lumbar Disc Fragment Masquerading as a Spinal Intradural Tumor 
Intervertebral intradural lumbar disc herniation (ILDH) is a quite rare pathology, and isolated intradural lumbar disc herniation is even more rare. Magnetic resonance imaging (MRI) may not be able to reveal ILDHs, especially if MRI findings show an intact lumbar disc annulus and posterior longitudinal ligament. Here, we present an exceedingly rare case of an isolated IDLH that we initially misidentified as a spinal intradural tumor, in a 54-year-old man hospitalized with a 2-month history of back pain and right sciatica. Neurologic examination revealed a positive straight leg raise test on the right side, but he presented no other sensory, motor, or sphincter disturbances. A gadolinium-enhanced MRI revealed what we believed to be an intradural extramedullary tumor compressing the cauda equina leftward in the thecal sac, at the L2 vertebral level. The patient underwent total L2 laminectomy, and we extirpated the intradural mass under microscopic guidance. Histologic examination of the mass revealed a degenerated nucleus pulposus.
doi:10.3340/jkns.2012.52.2.156
PMCID: PMC3467376  PMID: 23091677
Intradural disc herniation; Spinal intradural tumor; Magnetic resonance imaging
9.  Posteriorly migrated thoracic disc herniation: a case report 
Introduction
Posterior epidural migration of thoracic disc herniation is extremely rare but may occur in the same manner as in the lumbar spine.
Case presentation
A 53-year-old Japanese man experienced sudden onset of incomplete paraplegia after lifting a heavy object. Magnetic resonance imaging revealed a posterior epidural mass compressing the spinal cord at the T9-T10 level. The patient underwent emergency surgery consisting of laminectomy at T9-T10 with right medial facetectomy, removal of the mass lesion, and posterior instrumented fusion. Histological examination of the mass lesion yielded findings consistent with sequestered disc material. His symptoms resolved, and he was able to resume walking without a cane 4 weeks after surgery.
Conclusions
Pre-operative diagnosis of posterior epidural migration of herniated thoracic disc based on magnetic resonance imaging alone may be overlooked, given the rarity of this pathology. However, this entity should be considered among the differential diagnoses for an enhancing posterior thoracic extradural mass.
doi:10.1186/1752-1947-7-41
PMCID: PMC3582544  PMID: 23402642
Intervertebral disc herniation; Posterior migration; Thoracic spine
10.  Arachnoiditis Following Caudal Epidural Injections for the Lumbo-Sacral Radicular Pain 
Asian Spine Journal  2013;7(4):355-358.
Caudal epidural steroid injection is a very common intervention in treatment of low back pain and sciatica symptoms. Although extensively used, it is not devoid of complications. A few reports of chemical and infective arachnoiditis exist following lumbar epidural anaesthesia, but none following a caudal epidural steroid injection.We report a case of arachnoiditis following caudal epidural steroid injections for lumbar radiculopathy. The patient presented with contralateral sciatica, worsening low back pain and urinary retention few days following the injection, followed by worsening motor functions in L4/L5/S1 myotomes with resultant dense foot drop. Gadolinium-enhanced magnetic resonance imaging suggested infective arachnoiditis with diffuse enhancement and clumping of the nerve roots within the lumbar and sacral thecal sac. As the number of injections in the management of back pain and lumbo-sacral radicular pain is increasing annually, it is imperative to have a thorough understanding of this potentially dangerous complication and educate the patients appropriately.
doi:10.4184/asj.2013.7.4.355
PMCID: PMC3863664  PMID: 24353855
Caudal; Epidural; Low back pain; Sciatica; Arachnoiditis
11.  Delayed Postoperative Epidural Hematoma Presenting Only with Vesicorectal Disturbance 
Case Reports in Orthopedics  2013;2013:861961.
We present a rare case of delayed onset of epidural hematoma after lumbar surgery whose only presenting symptom was vesicorectal disturbance. A 68-year-old man with degenerative spinal stenosis underwent lumbar decompression and instrumented posterolateral spine fusion. The day after his discharge following an unremarkable postoperative course, he presented to the emergency room complaining of difficulty in urination. An MRI revealed an epidural fluid collection causing compression of the thecal sac. The fluid was evacuated, revealing a postoperative hematoma. After removal of the hematoma, his symptoms disappeared immediately, and his urinary function completely recovered. Most reports have characterized postoperative epidural hematoma as occurring early after operation and accompanied with neurological deficits. But it can happen even two weeks after spinal surgery with no pain. Surgeons thus may need to follow up patients for at least a few weeks because some complications, such as epidural hematomas, could take that long to manifest themselves.
doi:10.1155/2013/861961
PMCID: PMC3773434  PMID: 24073350
12.  Ordinary Disc Herniation Changing into Posterior Epidural Migration of Lumbar Disc Fragments Confirmed by Magnetic Resonance Imaging: A Case Report of a Successful Endoscopic Treatment 
Asian Spine Journal  2014;8(1):69-73.
The posterior epidural migration of lumbar disc fragments is an extremely rare event with an unknown pathogenesis. To the best of our knowledge, there are no previously reported cases of a change of ordinary disc herniation into the posterior epidural migration of lumbar disc fragments as confirmed by magnetic resonance imaging (MRI). A 26-year-old male presented to our department complaining of left buttock and lateral leg pain. An ordinary herniation was shown in the first MRI. The patient's unilateral symptoms changed into bilateral symptoms while awaiting admission to the hospital. Posterior migrated lumbar disc fragments were shown in the second MRI taken at the time of admission. Microendoscopic surgery providing a detailed observation of the region was performed. Our case indicates that an ordinary lumbar disc herniation may lead to the posterior migration of lumbar disc fragments, and that microendoscopic surgery may provide a treatment.
doi:10.4184/asj.2014.8.1.69
PMCID: PMC3939372  PMID: 24596608
Lumbar; Hernia; Endoscopy
13.  Lumbar Epidural Varix Mimicking Perineural Cyst 
Asian Spine Journal  2013;7(2):136-138.
Lumbar epidural varices are rare and usually mimick lumbar disc herniations. Back pain and radiculopathy are the main symptoms of lumbar epidural varices. Perineural cysts are radiologically different lesions and should not be confused with epidural varix. A 36-year-old male patient presented to us with right leg pain. The magnetic resonance imaging revealed a cystic lesion at S1 level that was compressing the right root, and was interpreted as a perineural cyst. The patient underwent surgery via right L5 and S1 hemilaminectomy, and the lesion was coagulated and removed. The histopathological diagnosis was epidural varix. The patient was clinically improved and the follow-up magnetic resonance imaging showed the absence of the lesion. Lumbar epidural varix should be kept in mind in the differential diagnosis of the cystic lesions which compress the spinal roots.
doi:10.4184/asj.2013.7.2.136
PMCID: PMC3669700  PMID: 23741553
Epidural; Varix; Perineural cyst; Surgery
14.  Surgical treatment of spontaneous intracranial hypotension secondary to degenerative cervical spine pathology: a case report and literature review 
European Spine Journal  2011;21(Suppl 4):422-427.
Objective and importance
A rare cause of intracranial hypotension is leakage of cerebrospinal fluid (CSF) through a dural breach from degenerative cervical spine pathology. To our knowledge there have been only four cases described in the English literature. Treatment is challenging and varies from case to case, with complete symptom resolution reported for only one patient. Herein we review the literature and describe our surgical management of a 46-year-old woman with symptomatic intracranial hypotension from the penetration of the cervical thecal sac.
Clinical presentation
The patient presented with a 3-month history of progressive orthostatic headaches. Magnetic resonance imaging demonstrated bilateral subdural hematomas and pachymeningeal gadolinium enhancement. An anterior epidural CSF collection commencing at a C4–5 calcified disc protrusion and osteophyte was evident on a computed tomography spinal myelogram.
Intervention
After three unsuccessful lumbar blood patches, we elected to attempt surgical removal of the causative pathology with exposure and primary closure of the dural defect by anterior cervical discectomy as described previously. After resection of the disc–osteophyte complex and dural exposure, immediate high volume egression of CSF mixed with blood at the surgical site. The dural defect was not visible but CSF egression promptly ceased. Cervical corpectomy for greater exposure and primary repair of the defect has been described, but we considered this unwarranted and felt the intraoperative blood collection formed a local blood patch. A collagen dural substitute membrane was inserted through the discectomy space for reinforcement.
Conclusion
Two months after this novel surgical blood patch procedure the patient was asymptomatic and follow-up imaging demonstrated complete resolution.
doi:10.1007/s00586-011-1979-z
PMCID: PMC3369066  PMID: 21874294
Spontaneous intracranial hypotension; Cerebrospinal fluid leak; Degenerative spine pathology; Cervical spine
15.  Thoracic disc herniation causing transient paraplegia coincident with epidural anesthesia: a case report 
Cases Journal  2009;2:6228.
Neurological deficits following epidural or spinal anesthesia are extremely rare. Transient paraplegia following epidural anesthesia in a patient with thoracic disc herniation has been presented. A 44-year-old woman developed paraplegia during the operation for vascular surgery of her legs under epidural anesthesia. Epidural hematoma or spinal cord ischemia was ruled out by magnetic resonance imaging of the thoracic and lumbar spine in which protruded disc at T11-12 level compressing the spinal cord has been verified. Patient responded well to steroid treatment and rehabilitation interventions. Physicians should be aware of preceding disc protrusions, which may have detrimental effects on spinal cord perfusion, as a cause of persistent or transient paraplegia before epidural anesthesia procedure. MRI is a valuable imaging option to rule out epidural anesthesia complications and coexisting pathologies like disc herniations.
doi:10.4076/1757-1626-2-6228
PMCID: PMC2769273  PMID: 19918563
16.  Idiopathic Hypertrophic Spinal Pachymeningitis : Report of Two Cases and Review of the Literature 
Idiopathic hypertrophic spinal pachymeningitis (IHSP) is a rare inflammatory disease characterized by hypertrophic inflammation of the dura mater and various clinical courses that are from myelopathy. Although many associated diseases have been suggested, the etiology of IHSP is not well understood. The ideal treatment is controversial. In the first case, a 55-year-old woman presented back pain, progressive paraparesis, both leg numbness, and voiding difficulty. Initial magnetic resonance imaging (MRI) demonstrated an anterior epidural mass lesion involving from C6 to mid-thoracic spine area with low signal intensity on T1 and T2 weighted images. We performed decompressive laminectomy and lesional biopsy. After operation, she was subsequently treated with steroid and could walk unaided. In the second case, a 45-year-old woman presented with fever and quadriplegia after a spine fusion operation due to lumbar spinal stenosis and degenerative herniated lumbar disc. Initial MRI showed anterior and posterior epidural mass lesion from foramen magnum to C4 level. She underwent decompressive laminectomy and durotomy followed by steroid therapy. However, her conditions deteriorated gradually and medical complications occurred. In our cases, etiology was not found despite through investigations. Initial MRI showed dural thickening with mixed signal intensity on T1- and T2-weighted images. Pathologic examination revealed chronic nonspecific inflammation in both patients. Although one patient developed several complications, the other showed slow improvement of neurological symptoms with decompressive surgery and steroid therapy. In case of chronic compressive myelopathy due to the dural hypertrophic change, decompressive surgery such as laminectomy or laminoplasty may be helpful as well as postoperative steroid therapy.
doi:10.3340/jkns.2011.50.4.392
PMCID: PMC3243847  PMID: 22200026
Idiopathic hypertrophic spinal pachymeningitis; Spinal cord compression; Chronic nonspecific inflammation; Dural thickening
17.  Paraspinal Abscess Communicated with Epidural Abscess after Extra-Articular Facet Joint Injection 
Yonsei Medical Journal  2007;48(4):711-714.
Facet joint injection is considered to be a safe procedure. There have been some reported cases of facet joint pyogenic infection and also 3 cases of facet joint infection spreading to paraspinal muscle and epidural space due to intra-articular injections. To the author's knowledge, paraspinal and epidural abscesses after facet joint injection without facet joint pyogenic infection have not been reported. Here we report a case in which extra-articular facet joint injection resulted in paraspinal and epidural abscesses without facet joint infection. A 50-year-old man presenting with acute back pain and fever was admitted to the hospital. He had the history of diabetes mellitus and had undergone the extra-articular facet joint injection due to a facet joint syndrome diagnosis at a private clinic 5 days earlier. Physical examination showed tenderness over the paraspinal region. Magnetic resonance image (MRI) demonstrated the paraspinal abscess around the fourth and fifth spinous processes with an additional epidural abscess compressing the thecal sac. The facet joints were preserved. The laboratory results showed a white blood cell count of 14.9 × 109 per liter, an erythrocyte sedimentation rate of 52mm/hour, and 10.88mg/dL of C-reactive protein. Laminectomy and drainage were performed. The pus was found in the paraspinal muscles, which was communicated with the epidural space through a hole in the ligamentum flavum. Cultures grew Staphylococcus aureus. Paraspinal abscess communicated with epidural abscess is a rare complication of extra-articular facet joint injection demonstrating an abscess formation after an invasive procedure near the spine is highly possible.
doi:10.3349/ymj.2007.48.4.711
PMCID: PMC2628056  PMID: 17722247
Complication; infection; injection; facet joint
18.  Herniated lumbar disc 
Clinical Evidence  2009;2009:1118.
Introduction
Herniated lumbar disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space. The highest prevalence is among people aged 30-50 years, with a male to female ratio of 2:1. There is little evidence to suggest that drug treatments are effective in treating herniated disc.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of drug treatments, non-drug treatments, and surgery for herniated lumbar disc? We searched: Medline, Embase, The Cochrane Library, and other important databases up to July 2008 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 49 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: acupuncture, advice to stay active, analgesics, antidepressants, bed rest, corticosteroids (epidural injections), cytokine inhibitors (infliximab), discectomy (automated percutaneous, laser, microdisectomy, standard), exercise therapy, heat, ice, massage, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), percutaneous disc decompression, spinal manipulation, and traction.
Key Points
Herniated lumbar disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space. The highest prevalence is among people aged 30-50 years, with a male to female ratio of 2:1.
There is little evidence to suggest that drug treatments are effective in treating herniated disc. NSAIDs and cytokine inhibitors don’t seem to improve symptoms of sciatica caused by disc herniation.We found no evidence examining the effectiveness of analgesics, antidepressants, or muscle relaxants in people with herniated disc.We found no evidence of sufficient quality to judge the effectiveness of epidural injections of corticosteroids.
With regard to non-drug treatments, spinal manipulation seems to be more effective at relieving local or radiating pain in people with acute back pain and sciatica with disc protrusion compared with sham manipulation, although concerns exist regarding possible further herniation from spinal manipulation in people who are surgical candidates. Neither bed rest nor traction seem effective in treating people with sciatica caused by disc herniation.We found insufficient evidence about advice to stay active, acupuncture, massage, exercise, heat, or ice to judge their efficacy in treating people with herniated disc.
About 10% of people have sufficient pain after 6 weeks for surgery to become a consideration. Both standard discectomy and microdiscectomy seem to increase self-reported improvement to a similar extent.We found insufficient evidence judging the effectiveness of automated percutaneous discectomy, laser discectomy, or percutaneous disc decompression.
PMCID: PMC2907819  PMID: 19445754
19.  Herniated lumbar disc 
Clinical Evidence  2011;2011:1118.
Introduction
Herniated lumbar disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space. The highest prevalence is among people aged 30 to 50 years, with a male to female ratio of 2:1. There is little evidence to suggest that drug treatments are effective in treating herniated disc.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of drug treatments, non-drug treatments, and surgery for herniated lumbar disc? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 37 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: acupuncture, advice to stay active, analgesics, antidepressants, bed rest, corticosteroids (epidural injections), cytokine inhibitors (infliximab), discectomy (automated percutaneous, laser, microdiscectomy, standard), exercise therapy, heat, ice, massage, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), percutaneous disc decompression, spinal manipulation, and traction.
Key Points
Herniated lumbar disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space. The highest prevalence is among people aged 30 to 50 years, with a male to female ratio of 2:1.
There is little high-quality evidence to suggest that drug treatments are effective in treating herniated disc. NSAIDs and cytokine inhibitors do not seem to improve symptoms of sciatica caused by disc herniation.We found no RCT evidence examining the effects of analgesics, antidepressants, or muscle relaxants in people with herniated disc. We found several RCTs that assessed a range of different measures of symptom improvement and found inconsistent results, so we are unable to draw conclusions on effects of epidural injections of corticosteroids.
With regard to non-drug treatments, spinal manipulation seems more effective at relieving local or radiating pain in people with acute back pain and sciatica with disc protrusion compared with sham manipulation, although concerns exist regarding possible further herniation from spinal manipulation in people who are surgical candidates. Neither bed rest nor traction seem effective in treating people with sciatica caused by disc herniation.We found insufficient RCT evidence about advice to stay active, acupuncture, massage, exercise, heat, or ice to judge their efficacy in treating people with herniated disc.
About 10% of people have sufficient pain after 6 weeks for surgery to become a consideration. Standard discectomy and microdiscectomy seem to increase self-reported improvement to a similar extent.We found insufficient evidence judging the effects of automated percutaneous discectomy, laser discectomy, or percutaneous disc decompression.
PMCID: PMC3275148  PMID: 21711958
20.  Intradural schwannoma complicated by lumbar disc herniation at the same level: A case report and review of the literature 
Oncology Letters  2014;8(2):936-938.
Intradural tumours of the spine are usually benign and have a good prognosis, if they are diagnosed and removed early. Lumbar disc herniation is a common cause of chronic, acute, or recurrent lumbar radiculopathy. However, to date, there have been no reports of progressive neurological deficiencies due to the co-existence of two significant pathologies contributing to intradural and extradural compression. The current study reports the rare case of a patient with simultaneous extradural and intradural compression of the nerve root due to co-existent intervertebral disc herniation and an intradural schwannoma at the same level. A 71-year-old female suffering from lower back pain and radiating pain of the right lower extremities was admitted to Busan Korea Hospital (Busan, Korea). Magnetic resonance imaging revealed lumbar disc herniation at L4–5 and a mass occupying the intradural space at the same level of the compressed dural sac. Using the posterior approach, surgical excision of the two pathologies was performed. Pathological diagnosis confirmed schwannoma and the symptoms markedly improved.
doi:10.3892/ol.2014.2181
PMCID: PMC4081376  PMID: 25013519
herniated intervertebral disc; intradural tumor; schwannoma
21.  Clinical correlation of magnetic resonance imaging with symptom complex in prolapsed intervertebral disc disease: A cross-sectional double blind analysis 
Introduction:
Low backache (LBA) is one of the most common problems and herniated lumbar disc is one of the most commonly diagnosed abnormalities associated with LBA. Disc herniation of the same size may be asymptomatic in one patient and can lead to severe nerve root compromise in another patient.
Objective:
To evaluate correlation between the clinical features of disc collapse and magnetic resonance imaging (MRI) finding to determine the clinical importance of anatomical abnormalities identified by MRI technique.
Summary:
From January 2010 to January 2012, 75 otherwise healthy patients (43 males 32 females) between the age of 19 and 55 years (average age was 44.5 years) with low back pain and predominant complaint of root pain who presented to our clinic were included in the study.
Materials and Methods:
Proper screening was done to rule out previous spine affection and subjected to MRI.
Results:
The results were analyzed under four headings viz. disc herniation, disc degeneration, thecal sac deformation and neural foramen effacement. All patients had a visual analog score (VAS) score more than 6. The interrater correlation coefficient kappa was calculated to be k=0.51. There were total 44 patients with herniation, 25 patients had mild, one patient had moderate degree of thecal sac deformation, 21 patients had one or more levels of foraminal effacement by the herniated tissue, 100% of the patients had disc degeneration ranging from grade 1 to 3 at different levels; and 48 patients (64%) had radiculopathy, six (8%) patients had bilateral and others had ipsilateral affection.
Conclusion:
In our study, the correlation was made between clinical findings and MRI findings. It can safely be concluded that treating physician should put more emphasis on history, clinical examination, and make the inference by these and then should correlate the clinical findings with that of MRI to reach a final diagnosis.
doi:10.4103/0974-8237.121619
PMCID: PMC3872655  PMID: 24381451
Disc degeneration; disc herniation; neural foramen effacement; thecal sac deformation
22.  Occurrence of Trochlear Nerve Palsy after Epiduroscopic Laser Discectomy and Neural Decompression 
The Korean Journal of Pain  2013;26(2):199-202.
Epiduroscopic laser discectomy and neural decompression (ELND) is known as an effective treatment for intractable lumbar pain and radiating pain which develop after lumbar surgery, as well as for herniation of the intervertebral disk and spinal stenosis. However, various complications occur due to the invasiveness of this procedure and epidural adhesion, and rarely, cranial nerve damage can occur due to increased intracranial pressure. Here, the authors report case in which double vision occurred after epiduroscopic laser discectomy and neural decompression in a patient with failed back surgery syndrome (FBSS).
doi:10.3344/kjp.2013.26.2.199
PMCID: PMC3629352  PMID: 23614087
epiduroscopic laser discectomy; failed back surgery syndrome; trochlear nerve palsy
23.  Full-endoscopic interlaminar removal of chronic lumbar epidural hematoma after spinal manipulation 
Background:
Spinal manipulation is widely used for low back pain treatments. Complications associated with spinal manipulation are seen. Lumbar epidural hematoma (EDH) is one of the complications reported in the literature. If lumbar chronic EDH symptoms are present, which are similar to those of a herniated nucleus pulposus, surgery may be considered if medical treatment fails. Percutaneous endoscopic discectomy utilizing an interlaminar approach can be successfully applied to those with herniated nucleus pulposus. We use the same technique to remove the lumbar chronic EDH, which is the first documented report in the related literature.
Methods:
We present a case with chronic lumbar EDH associated with spinal manipulation. Neurologic deficits were noted on physical examination. We arranged for a full-endoscopic interlaminar approach to remove the hematoma for the patient with the rigid endoscopy (Vertebris system; Richard Wolf, Knittlingen, Germany).
Results:
After surgery, the patient's radiculopathy immediately began to disappear. Magnetic resonance imaging (MRI) follow-up 10 days after the surgery revealed no residual hematoma. No complications were noted during the outpatient department follow up.
Conclusions:
Lumbar EDH is a possible complication of spinal manipulation. Patient experiencing rapidly progressive neurologic deficit require early surgical evacuation, while conservative treatment may only be applied to those with mild symptoms. A percutaneous full-endoscopic interlaminar approach may be a viable alternative for the treatment of those with chronic EDH with progressive neurologic deficits.
doi:10.4103/2152-7806.131106
PMCID: PMC4033759  PMID: 24872917
Chronic epidural hematoma; endoscopic; interlaminar; lumbar; spinal manipulation
24.  Acute spinal subdural hematoma complicating lumbar decompressive surgery 
Study design: A case report.
Objective: To report a rare case of acute spinal subdural hematoma (SSH) complicating lumbar spine surgery, its characteristic presenting symptoms, diagnostic imaging, possible cause, and pitfall in management.
Methods: A 59-year-old woman with lumbar spinal instability and stenosis underwent laminectomy and decompression at L3–L5 with instrumentation and fusion from L3–S1.
Results: Immediately following surgery, the patient presented with incapacitating pain of both lower extremities from the mid-thigh downward, which was not relieved by narcotic analgesia and was disproportional to surgical trauma. Left ankle and great toes weakness was detected at postoperative day 2 and deteriorated on day 6. Magnetic resonance imaging was performed urgently and revealed a characteristic SSH with thecal sac compression at the level of L2, proximal to the laminectomy. Emergency decompression and evacuation of the hematoma was performed. The patient had partial recovery 6 weeks postoperatively.
Conclusion: Acute SSH is a rare complication of lumbar spine surgery. This diagnosis must be considered when severe leg pain, unresolved with analgesia and disproportional to surgical trauma, with neurological deterioration occurring after lumbar spine surgery. Magnetic resonance imaging is the imaging modality of choice to assist in the differential diagnosis of an SSH. Early surgical decompression is necessary for optimal neurological recovery.
doi:10.1055/s-0031-1298602
PMCID: PMC3503516  PMID: 23236307
25.  Magnetic resonance imaging findings in low back pain and lower extremity radicular chronic pain 
Journal of Injury and Violence Research  2012;4(3 Suppl 1): Paper No. 37.
Abstract:
Background:
Low back pain (LBP) is one of the most prevalent complaints among the people worldwide. According to the medical statistics, about 80 percent of people have at least one episode of LBP during their lifetime cause them to visit a physician for treatment. LBP is the most prevalent cause of work disability and its related leaves among people under 45 years old. Numerous studies have been conducted on the connection between clinical signs, patients’ complaints, the level of lumbar disc herniation, and abnormal findings of magnetic resonance imaging (MRI). In many cases, contradictory views have been reported and even in some cases canal stenosis and herniated disc have been reported in patient without clinical sings. The aim of this study was to analyze MRI findings in patients with LBP and radicular chronic pain (RCP) attending Imam Reza Hospital (Kermanshah, Iran).
Methods:
This cross-sectional study was conducted on 200 patients (100 with LBP and 100 with RCP). Following unsuccessful results of medical treatment for 1 to 48 months, the examination results, demographic information (age, sex, job, etc.) and their complaints along with MRI findings were documented and statistically analyzed. Patients with history of lumbar surgery, infective inflammatory diseases, fractures, tumors, etc were excluded from the study. To determine the significant correlation between qualitative and quantitative variables, the Chi-Square test and the independent t-test were respectively performed using the statistical package of SPSS (Version 12) The P-value of less than 0.05 was considered significant.
Results:
In the LBP group, patients complained only of posterior and inferior spinal column pain and did not have any pain distribution toward lower limbs or any other signs. However, in the RCP group, in addition to pain distribution towards the lower limbs, they were complaining about muscular myotonia and sensational disorder and 88% also had low back pain. 94 of them were men and 106 were women.106 subjects (80.5%) were urban residents and 39 (19.5%) rural residents. There were 42.5% housewife, 21.5% employee, 15% workers, 9.5% self-employed, and 8.5% were unemployed. In terms of education, 27% were uneducated, 40.5% with incomplete high school diploma, and 32.5% with high school diploma and higher levels of education. 33.5% of patients had the treatment period of one month, while for the rest this period was more than one month to 4 years. Twenty percent did not rest, 52.5% rested up to 3 weeks and 24% rested up to 3 months. In the RCP group, 41% complained of pain in the right leg, 36% in the left leg, and 23% in both legs. However, in the RCP group, 26% had limb paresis, 5% atrophy, 25% some levels of sensational disorders, and 2% had sphincter disorders.
MRI findings:
Herniated disc in the form of protrusion and extrusion at L4-L5 and L5-S1 spaces were mainly observed in patients with RCP rather than those with LBP. Twenty-six patients (13%) had spondylolisthesis of which 12 (46.2%) were in LBP group and the other 14 patients (53.8) in RCP group. Forty-eight patients (24%) had canal stenosis of which 11 patients were from LBP group and 37 from RCP group. Of these 48 patients, 11 had partial stenosis and 37 had absolute stenosis that were in the RCP group.
Conclusions:
The most prevalent herniated disc spaces were at the levels of L4-L5 (87%) and S1-S2 (65%). This is because that most of the movements occur in the mobile parts of disc surface and the stresses that are exerted on the mentioned part. Generally, a meaningful correlation between existence of canal stenosis at L4-L5 and L5-S1 levels and the existence of pressure effect on nerve in THECAL SAC and lat recess in patients with RCP was seen; and also a meaningful correlation among muscular myotonia, radicular distribution of limbs’ pain along with compressive effects on the nerve in the lat recess and the thecal sac and spinal canal stenosis were observed. A significant correlation between complaints of RCP in lower limbs and muscular myotonia with these findings was seen but in analyzing the distributing pain patterns or muscular myotonia on the base of RCP such a correlation was not seen.
Keywords:
Low back pain, Radicular back pain, Magnetic resonance imaging
PMCID: PMC3571563

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