Systematic review of randomized clinical trials.
Review of current literature regarding the effectiveness of manual therapy in the treatment of cervical radiculopathy.
Cervical radiculopathy (CR) is a clinical condition frequently encountered in the physical therapy clinic. Cervical radiculopathy is a result of space occupying lesions in the cervical spine: either cervical disc herniations, spondylosis, or osteophytosis. These affect the pain generators of bony and ligamentous tissues, producing radicular symptoms (i.e. pain, numbness, weakness, paresthesia) observed in the upper extremity of patients with cervical nerve root pathology. Cervical radiculopathy has a reported annual incidence of 83·2 per 100 000 and an increased prevalence in the fifth decade of life among the general population.
Medline and CINAHL via EBSCO, Cochrane Library, and Google Scholar were used to retrieve the randomized clinical trial studies for this review between the years of 1995 and February of 2011. Four studies met inclusion criteria and were considered to be high quality (PEDro scores of ⩾5). Manual therapy techniques included muscle energy techniques, non-thrust/thrust manipulation/mobilization of the cervical and/or thoracic spine, soft-tissue mobilization, and neural mobilization. In each study, manual therapy was either a stand-alone intervention or part of a multimodal approach which included therapeutic exercise and often some form of cervical traction. Although no clear cause and effect relationship can be established between improvement in radicular symptoms and manual therapy, results are generally promising.
Although a definitive treatment progression for treating CR has not been developed a general consensus exists within the literature that using manual therapy techniques in conjunction with therapeutic exercise is effective in regard to increasing function, as well as AROM, while decreasing levels of pain and disability. High quality RCTs featuring control groups are necessary to establish clear and effective protocols in the treatment of CR.
Cervical radiculopathy; Conservative treatment; Manual therapy; Manipulation; Mobilization; Non-operative; Physiotherapy; Physical therapy
We report on a very rare case of a cervical ligamentum flavum cyst, which presented with progressive myelopathy and radiculopathy. The cyst was radically extirpated and our patient showed significant recovery. A review of the relevant literature yielded seven cases.
An 82-year-old Greek woman presented with progressive bilateral weakness of her upper extremities and causalgia, cervical pain, episodes of upper extremity numbness and significant walking difficulties. Her neurological examination showed diffusely decreased motor strength in both her upper and lower extremities. Magnetic resonance imaging of her cervical spine demonstrated a large, well-demarcated cystic lesion on the dorsal aspect of her spinal cord at the C3 to C4 level, significantly compressing the spinal cord at this level, in close proximity to the yellow ligament and the C3 left lamina. The largest diameter of this lesion was 1.4 cm, and there was no lesion enhancement after the intravenous administration of a paramagnetic contrast. The lesion was surgically removed after a bilateral C3 laminectomy. The thick cystic wall was yellow and fibro-elastic in consistency, while its content was gelatinous and yellow-brownish. A postoperative cervical-spine magnetic resonance image was obtained before her discharge, demonstrating decompression of her spinal cord and dural expansion. Her six-month follow-up evaluation revealed complete resolution of her walking difficulties, improvement in the muscle strength of her arms (4+/5 in all the affected muscle groups), no causalgia and a significant decrease in her preoperative upper extremity numbness.
Cervical ligamentum flavum cysts are rare benign lesions, which should be included in the list of differential diagnosis of spinal cystic lesions. They can be differentiated from other intracanalicular lesions by their hypointense appearance on T1-weighted and hyperintense appearance on T2-weighted magnetic resonance images, with contrast enhancement of the cystic wall. Surgical extirpation of the cyst is required for symptom alleviation and decompression of the spinal cord. The outcome of these cysts is excellent with no risk of recurrence.
Intervertebral disk herniation is relatively common. Migration usually occurs in the ventral epidural space; rarely, disks migrate to the dorsal epidural space due to the natural anatomical barriers of the thecal sac.
A 49-year-old man presented with 1 week of severe back pain with bilateral radiculopathy to the lateral aspect of his lower extremities and weakness of the ankle dorsiflexors and toe extensors. Lumbar spine magnetic resonance imaging with gadolinium revealed a peripheral enhancing dorsal epidural lesion with severe compression of the thecal sac. Initial differential diagnosis included spontaneous hematoma, synovial cyst, and epidural abscess. Posterior lumbar decompression was performed; intraoperatively, the lesion was identified as a large herniated disk fragment.
Dorsal migration of a herniated intervertebral disk is rare and may be difficult to definitively diagnose preoperatively. Dorsal disk migration may present in a variety of clinical scenarios and, as in this case, may mimic other epidural lesions on magnetic resonance imaging.
Vertebral disk, herniation; Back pain, radiculopathy; Abscess, epidural; Hematoma, epidural; Laminectomy; Decompression, lumbar
The development of a symptomatic herniated cervical disc before the age of 20 is extremely rare. Sporadically reported cases of patients with cervical disc herniation under the age of 20 usually have had underlying disease.
Case 1: A 19-year-old Asian man visited our clinic and presented with progressive pain in his upper left scapula and weakness of the left deltoid and biceps brachii muscles. C5 radiculopathy by soft disc herniation at C4-C5 without calcification was diagnosed. Microsurgical posterior foraminotomy was performed and he recovered completely eight weeks after the surgery.
Case 2: A 15-year-old Asian man presented with difficulty in lifting his arm and neck pain on the right side. Neurological examination showed weakness of the right deltoid and biceps brachii muscles. A magnetic resonance imaging scan demonstrated a herniated intervertebral disc in the right C4-C5 foramen. The patient was treated conservatively and put under observation only, and had completely recovered eight weeks after admission.
Although extremely rare, symptomatic cervical disc herniations may occur even in the younger population under the age of 20 without any trauma or underlying disease. Favorable outcomes can be achieved by conventional treatments for cervical disc herniation.
Hyperextension injury in the thoracic spine is uncommon with only a few cases documented in the literature. The mechanism of these injuries is hyperextension combined with axial or shearing force. These types of injuries are associated with a high risk of dural tears and paraplegia. A 91-year-old female presented with acute back pain from a hyperextension injury in thoracic spine with no neurological deficit. Lumbar magnetic resonance imaging showed a intervertebral disc rupture. On day 20 of hospitalization, the herniated intervertebral disc compressed the spinal cord with incomplete paraplegia. Hyperextension injuries involving the three columns are very unstable and we recommend surgical treatment as soon as possible, not only because of the initial trauma, but a ruptured disc herniation can damage the spinal cord.
Thoracic Vertebrae; Paraplegia; Disc herniation
To present the management of a patient with a cervical disc herniation and illustrate the efficacy of cervical traction as a main form of treatment for cervical disc herniation in conjunction with a home exercise program.
A 71-year-old white female diagnosed with cervical disc herniation at the levels of C5-6 and C6-7 presented to physical therapy with neck pain radiating into the left upper extremity down to the 5th digit of the left hand.
The patient reported to outpatient physical therapy for cervical disc herniation and radiculopathy. After initial evaluation she received intermittent cervical traction and was given a home exercise program consisting of cervical lateral flexion stretch, unilateral wall stretch for pectoralis muscles and to continue with her over the door cervical traction.
Cervical traction and a good home exercise program have been shown to reduce cervical disc herniation and its subsequent symptoms.
traction; cervical spine; disc herniation; radiculopathy
Brown-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.
Brown-Sequard syndrome; Cervical disc herniation; Microdiscectomy; Anterior cervical fusion
Posterior epidural migration of thoracic disc herniation is extremely rare but may occur in the same manner as in the lumbar spine.
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.
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.
Intervertebral disc herniation; Posterior migration; Thoracic spine
Large lumbosacral disc herniations effacing both the paramedian and the foraminal area often cause double radicular compression. Surgical management of these lesions may be difficult. A traditional interlaminar approach usually brings into view only the paramedian portion of the intervertebral disc, unless the lateral bone removal is considerably increased. Conversely, the numerous far-lateral approaches proposed for removing foraminal or extraforaminal disc herniations would decompress the exiting nerve root only. Overall, these approaches share the drawback of controlling the neuroforamen on one side alone. A combined intra-extraforaminal exposure is a useful yet rarely reported approach. Over a 3-year period, 15 patients with bi-radicular symptoms due to large disc herniations of the lumbar spine underwent surgery through a combined intra-extracanal approach. A standard medial exposure with an almost complete hemilaminectomy of the upper vertebra was combined with an extraforaminal exposure, achieved by minimal drilling of the inferior facet joint, the lateral border of the pars interarticularis and the inferior margin of the superior transverse process. The herniated discs were removed using key maneuvers made feasible by working simultaneously on both operative windows. In all cases the disc herniation could be completely removed, thus decompressing both nerve roots. Radicular pain was fully relieved without procedure-related morbidity. The intra-extraforaminal exposure was particularly useful in identifying the extraforaminal nerve root early. Early identification was especially advantageous when periradicular scar tissue hid the nerve root from view, as it did in patients who had undergone previous surgery at the same site or had long-standing radicular symptoms. Controlling the foramen on both sides also reduced the risk of leaving residual disc fragments. A curved probe was used to push the disc material outside the foramen. In conclusion, specific surgical maneuvers made feasible by a simultaneous extraspinal and intraspinal exposure allow quick, safe and complete removal of lumbosacral disc herniations with paramedian and foraminal extension.
Combined approach; Disc herniation; Foraminal; Lumbar
Cervical disc herniation often results in neck and arm pain in patients as a result of direct impingement of nerve roots and associated inflammatory processes. The clinical presentation usually corresponds with the side of herniation and ipsilateral symptoms predominate the clinical picture.
A 35-year-old Caucasian man presented to our facility with neck pain and left-sided upper and lower extremity pain. A magnetic resonance imaging scan revealed a right paramedian herniated disc at the C5 to C6 level. All other cervical levels were normal without central canal stenosis or neural foraminal stenosis. Results from magnetic reasonance imaging scans of the brain and lumbar spine were negative. An anterior cervical discectomy was performed at the C5 to C6 level, and an inter-body graft and plate were placed. Our patient had complete resolution of his neck and left arm pain.
Anterior discectomy and fusion of the cervical spine resulted in complete resolution of our patient’s neck and left arm symptoms and improvement of his contralateral left leg pain. Cervical disc herniation may present with contralateral symptoms that are different from the current perception of this disease.
Cervical; Contralateral symptoms; Disc herniation; Radiculopathy
Cervical radiculopathy is defined as a syndrome of pain and/or sensorimotor deficits due to compression of a cervical nerve root. Understanding of this disease is vital for rapid diagnosis and treatment of patients with this condition, facilitating their recovery and return to regular activity.
This review is designed to clarify (1) the pathophysiology that leads to nerve root compression; (2) the diagnosis of the disease guided by history, physical exam, imaging, and electrophysiology; and (3) operative and non-operative options for treatment and how these should be applied.
The PubMed database was searched for relevant articles and these articles were reviewed by independent authors. The conclusions are presented in this manuscript.
Facet joint spondylosis and herniation of the intervertebral disc are the most common causes of nerve root compression. The clinical consequence of radiculopathy is arm pain or paresthesias in the dermatomal distribution of the affected nerve and may or may not be associated with neck pain and motor weakness. Patient history and clinical examination are important for diagnosis. Further imaging modalities, such as x-ray, computed tomography, magnetic resonance imaging, and electrophysiologic testing, are of importance. Most patients will significantly improve from non-surgical active and passive therapies. Indicated for surgery are patients with clinically significant motor deficits, debilitating pain that is resistant to conservative modalities and/or time, or instability in the setting of disabling radiculopathy. Surgical treatment options include anterior cervical decompression with fusion and posterior cervical laminoforaminotomy.
Understanding the pathophysiology, diagnosis, treatment indications, and treatment techniques is essential for rapid diagnosis and care of patients with cervical radiculopathy.
cervical radiculopathy; disc herniation; ACDF; ADF; posterior cervical laminoforaminotomy; posterior cervical foraminotomy
Intradural lumbar disc herniation is a rare complication of disc disease. The reason for the tearing of the dura matter by a herniated disc is not clearly known. Intradural disc herniations usually occur at the disc levels and are often seen at L4–L5 level but have also been reported at other intervertebral disc levels. However, intradural disc herniation at mid-vertebral levels is rare in the literature and mimics an intradural extramedullary spinal tumor lesion in radiological evaluation. Although magnetic resonance imaging (MRI) with gadolinium is useful in the diagnosis of this condition, preoperative correct diagnosis is usually difficult and the definitive diagnosis must be made during surgery. We describe here a 50-year-old female patient who presented with pain in the lower back for 6 months and a sudden exacerbation of the pain that spread to the left leg as well as numbness in both legs for 2 weeks. MRI demonstrated an intradural mass at the level of L5. Laminectomy was performed, and subsequently durotomy was also performed. An intradural disc fragment was found and completely removed. The patient recovered fully in 3 months. Intradural lumbar disc herniation must be considered in the differential diagnosis of mass lesions in the spinal canal.
Intervertebral disc herniation; Intradural disc herniation; Intraspinal tumor; L5
The management of a patient with L4 radiculopathy with side posture spinal manipulative therapy (SMT) is described. Dramatic improvement both subjectively and objectively followed a short course of SMT of the lumbar spine. This case is used to illustrate aspects of the natural history of lumbar discogenic radiculopathy, safety and effectiveness of SMT for disc herniations, diagnostic imaging, and differentiation of referred vs. radicular pain syndromes. Also included is a short summary of the safety and effectiveness of surgery for lumbar disc herniation. We conclude that side posture SMT in this case was safe and may be effective in the treatment of presumed lumbar spine disc herniation with L4 radiculopathy.
chiropractic; spinal manipulation; lumbar disc herniation; radiculopathy
We wished to evaluate the incidence of non-contiguous spinal injury in the cervicothoracic junction (CTJ) or the upper thoracic spines on cervical spinal MR images in the patients with cervical spinal injuries.
Materials and Methods
Seventy-five cervical spine MR imagings for acute cervical spinal injury were retrospectively reviewed (58 men and 17 women, mean age: 35.3, range: 18-81 years). They were divided into three groups based on the mechanism of injury; axial compression, hyperflexion or hyperextension injury, according to the findings on the MR and CT images. On cervical spine MR images, we evaluated the presence of non-contiguous spinal injury in the CTJ or upper thoracic spine with regard to the presence of marrow contusion or fracture, ligament injury, traumatic disc herniation and spinal cord injury.
Twenty-one cases (28%) showed CTJ or upper thoracic spinal injuries (C7-T5) on cervical spinal MR images that were separated from the cervical spinal injuries. Seven of 21 cases revealed overt fractures in the CTJs or upper thoracic spines. Ligament injury in these regions was found in three cases. Traumatic disc herniation and spinal cord injury in these regions were shown in one and two cases, respectively. The incidence of the non-contiguous spinal injuries in CTJ or upper thoracic spines was higher in the axial compression injury group (35.3%) than in the hyperflexion injury group (26.9%) or the hyperextension (25%) injury group. However, there was no statistical significance (p > 0.05).
Cervical spinal MR revealed non-contiguous CTJ or upper thoracic spinal injuries in 28% of the patients with cervical spinal injury. The mechanism of cervical spinal injury did not significantly affect the incidence of the non-contiguous CTJ or upper thoracic spinal injury.
Spine, MR; Spine, injuries; Trauma
Posterior cervical laminoforaminotomy is an effective treatment for cervical radiculopathy due to disc herniations or spondylosis. Over the last decade, minimally invasive (i.e., percutaneous) procedures have become increasingly popular due to a smaller incision size and presumed benefits in postoperative outcomes. We performed a systematic review of the literature and identified studies of open or percutaneous laminoforaminotomy that reported one or more perioperative outcomes. Of 162 publications found by our initial screening, 19 were included in the final analysis. Summative results indicate that patients undergoing percutaneous cervical laminoforaminotomy have lower blood loss by 120.7 mL (open: 173.5 mL, percutaneous: 52.8 mL, n = 670), a shorter surgical time by 50.0 minutes (open: 108.3 minutes, percutaneous: 58.3 minutes, n = 882), less inpatient analgesic use by 25.1 Eq (open: 27.6 Eq, percutaneous: 2.5 Eq, n = 356), and a shorter hospital stay by 2.2 days (open: 3.2 days, percutaneous: 1.0 days, n = 1472), compared with patients undergoing open procedures. However, the heterogeneous nature of published data calls into question the reliability of these summative results. Further structured trials should be conducted to better characterize the risks and benefits of percutaneous laminoforaminotomy.
cervical spine; laminoforaminotomy; minimally invasive spine surgery; percutaneous spine surgery; spine surgery outcomes
Discal cyst is an intraspinal cyst with a distinct communication with the corresponding intervertebral disc. It is a rare condition and could present with radiculopathy similar to that caused by lumbar disc herniation. We present a patient with a large discal cyst in the ventrolateral epidural space of the 5th lumbar vertebral (L5) level that communicated with the adjacent 4th lumbar and 5th lumbar intervertebral disc, causing L5 radiculopathy. We alleviated the radiating pain with selective transforaminal epidural blocks.
epidural; injections; intervertebral disc displacement; radiculopathy; spine
An association between progression of cervical disc degeneration and that of lumbar disc degeneration has been considered to exist. To date, however, this association has not yet been adequately studied. Age-related changes in the cervical intervertebral discs were evaluated by magnetic resonance imaging (MRI) in patients with lumbar disc herniation, and compared with the MRI findings of healthy volunteers without lower back pain. The purpose of this study was to clarify whether the prevalence of asymptomatic cervical disc degeneration is higher in patients with lumbar disc herniation than in healthy volunteers. The study was conducted on 51 patients who were diagnosed as having lumbar disc herniation and underwent cervical spine MRI. The patients consisted of 34 males and 17 females ranging in age from 21–83 years (mean 46.9 ± 14.5 years) at the time of the study. The control group was composed of 113 healthy volunteers (70 males and 43 females) aged 24–77 years (mean 48.9 ± 14.7 years), without neck pain or low back pain. The percentage of subjects with degenerative changes in the cervical discs was 98.0% in the lumbar disc herniation group and 88.5% in the control group (p = 0.034). The presence of lumbar disc herniation was associated significantly with decrease in signal intensity of intervertebral disc and posterior disc protrusion in the cervical spine. None of the MRI findings was significantly associated with the gender, smoking, sports activities, or BMI. As compared to healthy volunteers, patients with lumbar disc herniation showed a higher prevalence of decrease in signal intensity of intervertebral disc and posterior disc protrusion on MRI of the cervical spine. The result of this study suggests that disc degeneration appears to be a systemic phenomenon.
Lumbar disc herniation; Asymptomatic volunteers; MRI; Cervical spine; Disc degeneration
Prospective Observational Cohorts
To describe sociodemographic and clinical features, and non-operative (medical) resource utilization prior to enrollment, in patients who are candidates for surgical intervention for intervertebral disc herniation (IDH), spinal stenosis (SpS), and degenerative spondylolisthesis (DS) according to SPORT criteria.
Summary of Background Data
Intervertebral disc herniation, spinal stenosis, and degenerative spondylolisthesis with stenosis are the three most common diagnoses of low back and leg symptoms for which surgery is performed. There is a paucity of descriptive literature examining large patient cohorts for the relationships among baseline characteristics and medical resource utilization with these three diagnoses.
The Spine Patient Outcomes Research Trial (SPORT) conducts three randomized and three observational cohort studies of surgical and non-surgical treatments for patients with IDH, SPS, and DS. Baseline data include demographic information, prior treatments received, and functional status measured by SF-36 and the Oswestry Disability Index (ODI-AAOS/Modems version). The data presented represents all 1,417 patients (745 IDH, 368 SpS, 304 DS) enrolled in the SPORT observational cohorts. Multiple logistic regression was used to generate independent predictors of utilization adjusted for sociodemographic variables, diagnosis, and duration of symptoms.
The average age was 41 years for the IDH group, 64 years for the SPS group, and 66 years for the DS group.
At enrollment, IDH patients presented with the most pain as reported on the SF-36 (BP 26.2 vs 33 SPS and 33.7 DS) and were the most impaired (ODI 51 vs 42.3 SPS and 41.5 DS). IDH patients utilized more chiropractic treatment (42% vs 33% SPS and 26% DS); had more Emergency Department (ED) visits (21% vs 7 % SPS and 4% DS); and used more opiate analgesics (50% vs 29% SPS and 28% DS).
After adjusting for age, gender, diagnosis, education, race, duration of symptoms, and compensation, Medicaid patients used significantly more opiate analgesics (58% Medicaid vs 41% no insurance, 42% employer, 33% Medicare, and 32% private) and had more ED visits compared to other insurance types. (31% Medicaid vs 22% no insurance, 16% employer, 3% Medicare, and 11% private).
IDH patients appear to have differences in sociodemographics, resource utilization, and functional impairment when compared to the SpS/DS patients. In addition, the differences in resource utilization for Medicaid patients may reflect differences in access to care. The data provided from these observational cohorts will serve as an important comparison to the SPORT randomized cohorts in the future.
SPORT; Disc herniation; spinal stenosis; degenerative spondylolisthesis; epidemiology; outcomes; utilization of healthcare resources
This study was done to present our surgical experience of modified transcorporeal anterior cervical microforaminotomy (MTACM) assisted by the O-arm-based navigation system for the treatment of cervical disc herniation. We present eight patients with foraminal disc herniations at the C5–C6, C6–C7, and C7–T1 levels. All patients had unilateral radicular arm pain and motor weakness. The inclusion criteria for the patients were the presence of single-level unilateral foraminal cervical disc herniation manifesting persistent radiculopathy despite conservative treatment. Hard disc herniation, down-migrated disc herniation, concomitant moderate to severe bony spur and foraminal stenosis were excluded. We performed MTACM to expose the foraminal area of the cervical disc and removed the herniated disc fragments successfully using O-arm-based navigation. Postoperatively, the patients’ symptoms improved and there was no instability during the follow-up period. MTACM assisted by O-arm-based navigation is an effective, safe, and precise minimally invasive procedure that tends to preserve non-degenerated structures as much as possible while providing a complete removal of ruptured disc fragments in the cervical spine.
Cervical disc herniation; Modified transcorporeal anterior cervical microforaminotomy; Minimally invasive; Navigation; O-arm
Elite wrestlers place tremendous stress through their cervical spine. These athletes are at risk for cervical trauma and may develop radiculopathy from recurrent episodes of injury. Team physicians and athletic trainers are faced with the challenge of treating these injuries in such a way as to allow the athlete to safely and expeditiously return to competition. Epidural steroid injections can be a successful complement to a conservative treatment algorithm for these complex injuries.
Five upper-level NCAA collegiate wrestlers who experienced symptomatic cervical radiculopathy were identified from an archival review. The majority of the athletes had MRI evidence of cervical disc disease, with corresponding subjective complaints and physical examination findings including pain and weakness that precluded continued competition. All athletes were treated conservatively with initial activity modification, strengthening, rehabilitation, NSAIDs, and, ultimately, cervical epidural steroid injections.
All five athletes successfully returned to competition without negative clinical sequelae or need for operative intervention. The athletes demonstrated subjective improvement in their symptoms and strength, and all were able to return to a high level of competition. The cervical epidural steroid injections were found to be safe, effective, and well tolerated in all of the athletes.
Elite wrestlers with cervical radiculopathy can be effectively and safely managed with a conservative regimen that includes cervical epidural steroid injections, which may allow them to continue to compete at a high level.
Prospective randomized and observational cohorts.
To compare outcomes of patients with and without workers' compensation who had surgical and nonoperative treatment for a lumbar intervertebral disc herniation (IDH).
Summary of Background Data
Few studies have examined the association between worker's compensation and outcomes of surgical and nonoperative treatment.
Patients with at least 6 weeks of sciatica and a lumbar IDH were enrolled in either a randomized trial or observational cohort at 13 US spine centers. Patients were categorized as workers' compensation or nonworkers' compensation based on baseline disability compensation and work status. Treatment was usual nonoperative care or surgical discectomy. Outcomes included pain, functional impairment, satisfaction and work/disability status at 6 weeks, 3, 6, 12, and 24 months.
Combining randomized and observational cohorts, 113 patients with workers' compensation and 811 patients without were followed for 2 years. There were significant improvements in pain, function, and satisfaction with both surgical and nonoperative treatment in both groups. In the nonworkers' compensation group, there was a clinically and statistically significant advantage for surgery at 3 months that remained significant at 2 years. However, in the workers' compensation group, the benefit of surgery diminished with time; at 2 years no significant advantage was seen for surgery in any outcome (treatment difference for SF-36 bodily pain [−5.9; 95% CI: −16.7–4.9] and physical function [5.0; 95% CI: −4.9–15]). Surgical treatment was not associated with better work or disability outcomes in either group.
Patients with a lumbar IDH improved substantially with both surgical and nonoperative treatment. However, there was no added benefit associated with surgical treatment for patients with workers' compensation at 2 years while those in the nonworkers' compensation group had significantly greater improvement with surgical treatment.
workers' compensation; disability; lumbar disc herniation; sciatica; outcomes; treatment; predictors; SPORT
The acute onset of neck pain and arm weakness is most commonly due to cervical radiculopathy or inflammatory brachial plexopathy. Rarely, extracranial vertebral artery dissection may cause radiculopathy in the absence of brainstem ischemia. We describe a case of vertebral artery dissection presenting as cervical radiculopathy in a previously healthy 43-year-old woman who presented with proximal left arm weakness and neck pain aggravated by movement. Cervical magnetic resonance imaging (MRI) and angiography revealed dissection of the left vertebral artery with an intramural hematoma compressing the left C5 and C6 nerve roots. Antiplatelet treatment was commenced, and full power returned after 2 months. Recognition of vertebral artery dissection on cervical MRI as a possible cause of cervical radiculopathy is important to avoid interventions within the intervertebral foramen such as surgery or nerve root sleeve injection. Treatment with antithrombotic agents is important to prevent secondary ischemic events.
Vertebral artery dissection; Neck pain; Radiculopathy; Cervical spine
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.
Lumbar disc herniation; Dorsal; Intradural; Migrated
Ischiofemoral impingement syndrome is known as one of the causes of hip pain due to impingement of ischium and femur, and usually correlated with trauma or operation. We report a rare case of ischiofemoral impingement syndrome that has no history of trauma or surgery. A 48-year-old female patient was referred for 2 months history of the left hip pain, radiating to lower extremity with a hip snapping sensation. She had no history of trauma or surgery at or around the hip joint and femur. The magnetic resonance imaging (MRI) of the lumbar spine showed no abnormality, except diffuse bulging disc without cord compression at the lumbosacral area. Electrophysiologic study was normal, and there were no neurologic abnormalities compatible with the lumbosacral radiculopathy or spinal stenosis. Hip MRI revealed quadratus femoris muscle edema with concurrent narrowing of the ischiofemoral space. The distance of ischiofemoral space and quadratus femoris space were narrow. It was compatible with ischiofemoral impingement syndrome. After treatment with nonsteroidal anti-inflammatory drugs, physical therapy, and exercise program, the patient's pain was relieved and the snapping was improved. To our knowledge, this is the first reported case of a nontraumatic, noniatrogenic ischiofemoral impingement syndrome, and also the first case to be treated by a nonsurgical method in the Republic of Korea.
Ischiofemoral; Impingement; Impingement syndrome
Chronic low back pain can be a manifestation of lumbar degenerative disease, herniation of intervertebral discs, arthritis, or lumbar stenosis. When nerve roots are compromised, low back pain, with or without lower extremity involvement, may occur. Local inflammatory processes play an important role in patients with acute lumbosciatic pain. The purpose of this study was to assess the value of erythrocyte sedimentation rate (ESR) and high sensitivity C-reactive protein (hsCRP) measurements in patients with chronic low back pain or radiculopathy.
ESR and hsCRP were measured in 273 blood samples from male and female subjects with low back pain and/or radiculopathy due to herniated lumbar disc, spinal stenosis, facet syndrome, and other diseases. The hsCRP and ESR were measured prior to lumbar epidural steroid injection.
The mean ESR was 18.8 mm/h and mean hsCRP was 1.1 mg/L. ESR had a correlation with age.
A significant systemic inflammatory reaction did not appear to arise in patients with chronic low back pain.
ESR; hsCRP; low back pain