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Epidural steroid injections should theoretically diminish inflammation in the epidural space and lead to improvement in symptoms resulting from neural compression. Epidural injections are commonly used in the setting of spinal stenosis with neurogenic claudication, and unilateral or bilateral radiculopathy from disc prolapse. A recent study by Wang et al.62 suggests that epidural steroid therapy benefits patients with lumbar disc prolapse and radiculopathy. In this retrospective review, 69 patients were studied. At an average follow-up of 1.5 years, 77 had resolutions of symptoms significant enough to cause them to decline surgical intervention. Riew et al.63 studied the effect of selective nerve root injections on patients with radiculopathy from disc prolapse or foraminal stenosis. These authors found that 53 of patients were able to obtain sufficient pain relief to be able to forgo a surgical solution. However, Carette et al.,64 in a randomized prospective double-blind study,...
Central spinal canal stenosis may be developmental, acquired, or a combination of the two. Developmental stenosis is relatively uncommon and is estimated to account for approx 15 of all cases of spinal stenosis. It may be idiopathic or related to a more generalized disorder affecting the skeletal system, as in the case of the mucopolysaccharidoses or Down's syndrome. The idiopathic variant may selectively involve the lumbar region or may be generalized. It results from the formation of short pedicles with a resulting decrease in the cross-sectional diameter of the central canal. In isolation, this abnormality is generally not symptomatic but renders the patient more susceptible to relatively mild derangements of the disc or posterior elements. Acquired central spinal stenosis may be caused by various abnormalities related to degeneration of the intervertebral disc (vertebral osteophyte, circumferential disc bulge, focal disc protrusion or extrusion), facet joints (osteophyte, synovial...
Lumbosacral disk disease and lumbar strain. The clinical feature of pain intensifying with rest and improving on exercise in spondylitic patients may be useful. Although sciatica-like pain may occur in AS, accompanying neurologic signs of lumbar root compression are unusual.
Fractures of the acetabulum are significant skeletal injuries. Seventy-five per cent follow RTAs. Fifty per cent are associated with other major fractures or injuries. The fracture may be associated with dislocation of the hip and impaired sciatic nerve function. Femoral head dislocation should be reduced as an emergency and traction maintained until a definitive management plan for the fracture is devised - occasionally the femoral head may be incarcerated in the fracture or peri-acetabular muscles. The most important prognostic factors are the velocity of the injury, the restoration of congruity of the weight-bearing surface of the dome of the acetabulum and the stability of the femoral head.
Caragee et al. conducted a prospective study of 8 patients (24 discs) with no history of lower back pain who had undergone posterior iliac bone graft. They found that 50 experienced concordant pain of the usual gluteal area. Thus, the ability of a patient to separate concordant Finally, Carragee also prospectively studied patients with and without lower back pain after laminotomy and discectomy. From a cohort of240 patients who had undergone single-level discectomy, 20 asymptomatic patients with normal psychometric test results were recruited for three-level discography. A control group consisted of 27 symptomatic patients who had undergone single-level discectomy. The asymptomatic patients had a 40 rate of positive injection, while the symptomatic group had a rate of 63 (49).
Respiratory failure, myocardial infarction, cardiac arrhythmias, congestive heart failure, pulmonary and fat embolism syndrome). Occasionally, a formal neurologic consultation and workup are necessary, although the results are generally unrevealing. 2. Neuropraxias arise particularly after surgery of the upper and lower extremities. These are generally a compression-related phenomenon resulting from prolonged positioning of the extremity during surgery or casting. All persons involved in the postoperative care of orthopedic patients must keep this problem in mind, as early detection is critical to the ultimate recovery of nerve function. Patients with antecedent subclinical neuropathy are prone to the development of these lesions following surgery. Peroneal nerve palsy may occur following complex knee surgery (valgus deformity) and sciatic nerve palsy after revision or complex total hip replacement.
Diagnosis of many avulsive injuries is generally made by history and mechanism of injury along with radiographs. Curvilinear or amorphous bone material is generally seen adjacent to the insertion site of concern although discrete bone fragments may not be seen with pubic symphyseal avulsion 58 . MR usually detects injury as a result of surrounding inflammation but subtle cortical bone fragments often manifest as dark signal voids and can be difficult to detect (Fig. 21). MR in the acute setting reassures that the myotendinous unit or tendon insertions are intact. In the younger child without apophyseal calcifications, MR is useful for diagnosis as radiographs may be negative 88 . Most avulsive injuries are treated conservatively but it is important to comment on a displaced avulsion greater than 2 cm, as the may need to undergo surgical repair 88-90 . Also hamstring avulsion injuries are more prone to complication because of proximity to the sciatic nerve and can be evaluated with MRI...
Pelvic images of a 50-year-old female who presented with lower back pain and sensory deficit associated with a recurrent giant cell cancer of the sacrum. A preoperative PVA embolization was performed to reduce the intraoperative blood loss. (A) Contrast-enhanced T1-weighted image shows the patchy and irregular enhancement of the sacral body and epidural space (arrows). The nerve roots are encased in the tumor tissue. (B) Pelvic angiogram shows the tumor blood supply from both internal iliac artery branches and the median sacral artery. Figure 16.7. Pelvic images of a 50-year-old female who presented with lower back pain and sensory deficit associated with a recurrent giant cell cancer of the sacrum. A preoperative PVA embolization was performed to reduce the intraoperative blood loss. (A) Contrast-enhanced T1-weighted image shows the patchy and irregular enhancement of the sacral body and epidural space (arrows). The nerve roots are encased in the tumor tissue. (B) Pelvic...
The patterns of pain referral from the SI joint are variable and are thus difficult to distinguish from other causes of low back pain.2,14-16 Presenting symptoms and signs include lower lumbar pain, buttock pain, groin pain, lower abdominal pain, pain radiating to the leg or foot, and focal pain and tenderness over the joint.1,2,14,15,17,18 The complex pain referral patterns are explained by the innervation of the joint. The SI joint and the sacroiliac ligaments contain myelinated and un-myelinated axons that are thought to conduct proprioception and pain sensation from mechanoreceptors and free nerve endings in the joint.19-21 The anterior aspect of the sacroiliac joint likely derives the majority of its innervation from the dorsal rami of the L1-S2 roots but may also be innervated by the obturator nerve, superior gluteal nerve, and lumbosacral trunk.13,22-24 The posterior aspect of the joint is innervated by the dorsal rami of L4-S4, with major contributions from S1 and S2.19,22-24...
North et al.56 performed diagnostic nerve blocks in a randomized prospective manner. In this study, 33 patients underwent a battery of local anesthetic blocks in an attempt to evaluate sciatica. The specificity of sciatic nerve block was 24 immediately and 36 at 1 hour. The sensitivity of selective nerve root blockade was 91 immediately and 88 at 1 hour. When analyzed in the context of blocks (from proximal to distal), the root block alone yielded significant pain relief in 9 immediately and 21 at 1 hour. The root block yielded greater relief of pain than any other block in 30 of patients immediately and 42 at 1 hour. In all other cases the sciatic block or facet block yielded equal or better results.
Delamination, or micro-fractures of collagen fibrils leading to mechanical distortion of the annular lamellae and sensitization of nociceptors with release of substance P. In fact, provocative discography triggers substance P release (11). As a result of stimulation of the dorsal root ganglion or direct chemical irritation of the nerve roots, the patient may experience referred pain to the buttocks and legs (39). Patients may present with one of three general types of disc pathologies. The first is the classic leg pain disc caused by disc herniation with nuclear migration through an annular tear and sciatica due to true dural tension. The internally disrupted disc with annular pathology, which produces back pain and variable amounts of buttock and leg pain but no true radiculopathy, causes the back pain disc. The mixed pattern of painful disc disease presents with features of both pathologies caused by small, contained disc herniations and central herniations.
A morphological adaptation of vertebrates that increases the spike propagation velocity on their axons is myelinization. An electron micrograph of the cross section of a myelinated axon is shown in Figure 1.2-5 (from a rat sciatic nerve, x 52,000). Where the axon is wrapped in the myelin tape, two important changes occur in the cable parameters. Because of the insulation of multiple, close-packed layers of UM, gm decreases, perhaps by a factor of 1 64. Because of the effective thickening of the axon wall, Cm and cm decrease by a factor of about 1 20. Thus, the effective space constant of the covered axon increases by about eight-fold, and the passive velocity of propagation, which is proportional to (ri cm)-1, increases by about 20-fold. Once a spike has been initiated at the SGL, it propagates down the axon to the first myelin bead. There it propagates electrotonically because the myelin blocks the high JNa and JK required for conventional regenerative propagation. Because of the...
In cases of a herniated disk (Fig. 19-13), the central mass (nucleus pulposus) of an intervertebral disk protrudes through the weakened outer ring (anulus fibrosus) of the disk into the spinal canal. This commonly occurs in the lumbosacral or cervical regions of the spine as a result of injury or heavy lifting. The herniated or slipped disk puts pressure on the spinal cord or spinal nerves, often causing pain along the sciatic nerve (sciatica). There may be spasms of the back muscles, leading to disability.
Additional tests are sometimes useful. The 'bowstring sign' is another useful test and may be tised to confirm nerve root irritalion. If there is still doubt as to whether there is sciatic nerve root irritation, for example where malingering is suspected, other manoeuvres may be tried, such as the 'flip test' (Fig. 8.13). Fig. B.11 Stretch tests - sciatic nerve roots. Neutral nerve roots slack. BD Straight leg raising limited by tension ol root over prolapsed disc, c Tension increased by dorsillexion ol foot (Bragaard test). El Root tension relieved by flexion at the knee. H With knee extension over prolapsed disc causing pain radiating to the back (Laseguetest), El Pressure over centre of popliteal fossa bears on posterior tibial nerve which is 'bowstrlnging' across the fossa causing pain locally and radiation into the back.
Symptoms and signs of LM may be secondary to CSF obstruction and hydrocephalus (headache), cranial nerve involvement, involvement of the region of the fourth ventricle (intractable vomiting), irritation compression of spinal nerve roots or spinal cord, or irritation of the cerebral cortex (seizures).5'38'39'46'52'53'56'70'77 The key to the diagnosis of LM in a CNS tumor patient often lies in detecting symptoms and signs related to nervous system involvement in a new location. A typical scenario would be a patient with a supratentorial tumor presenting with new lower cranial nerve findings, or a cervical or lumbar radiculopathy. The extent of meningeal spread may be quite advanced by the time the diagnosis of LM is made. Table 2 shows a list of symptoms and signs that are possible in patients with LM however, these findings may also be seen in patients with primary CNS tumors without LM.
If intravenous infusion is not possible, chloroquine and quinine may be given by intramuscular injection into the anterior thigh (not into the buttock, where absorption is slow and uncertain and the sciatic nerve is at risk). Chloroquine - but not quinine - may also be given by subcutaneous injection.
Several published studies describe clinical trials of magnets. The results of these studies, whether they show an effect or lack of effect for magnets, are typically contested by others. For example, a randomized, double-blind, placebo-controlled cross-over pilot study examined the effect of bipolar magnets on lower back pain 27 . Nineteen men and women with stable lower back pain of duration 6 months and greater were eligible and participated in the study. Real (300 Gauss) and sham magnetic devices which were similar in appearance were applied to the patient's skin, covered with cloth, and then wrapped with a smooth gold-colored foil. Participants underwent 6 hour treatments three times per week for 2 weeks. They rated their pain on a visual analogue scale before and after each treatment. At the end of each week's treatment, subjects responded to the Pain Rating Index of the McGill Pain Questionnaire and were rated for range of motion in the lumbrosacral spine by a clinician. There...
A remarkable improvement in pain control occurred some years ago with the presentation of a 50-year-old hotel cook who for years had been trying to convince doctors that there was a physical cause for her severe lower back pain and left-sided sciatica. No specific lesion had been demonstrated after intensive investigations, including lumbar puncture and myelography yet she continued to complain of searing pain and paraesthesiae in one of her lower limbs on a constant basis. Under hypnosis she was asked to
Pain Clinic II intradural and extradural corticosteroids for sciatica. Anesth Analg 51 990-999 1972. 4. Olmarker K, Rydevik B, et al. Pathophysiology of sciatica. Orthop Clin North Am 22 223-233, 1991. 17. Kuslich SD, Ulstrom CL, et al. The tissue origin of low back pain and sciatica. Orthop Clin North Am 22 181-187, 1991. 21. Racz GB, Noe C, et al. Selective spinal injections for lower back pain. Curr Rev Pain 3 333-341, 1999.
Normally active hand motion is essential to promote venous and lymphatic drainage. Any condition that causes an absence or decline of hand motion will promote the collection of edematous fluid and lead to diffuse hand swelling, stiffness, and ultimately loss of function. Bed rest and inactivity resulting from an unrelated condition (myocardial infarction, skeletal traction, sciatica) may lead to this potentially disabling condition. Physician awareness of the problem and the services of a trained therapist are essential to manage the problem.
The anterior head of the adductor magnus (as well as other muscles in the adductor group) receives innervation by the obturator nerve. The posterior head is innervated by branch of sciatic nerve like other hamstrings and functionally resembles a hamstring muscle. The adductor head of the magnus has a proximal attachment on the ischial ramus and inserts distally along the entire linea aspera. The posterior head has proximal attachment on the ischial tuberosity anteroinferiorly and distally attaches on the medial distal femur on the adductor tubercle.
Epidural corticosteroid agents for sciatica. Med J Aust 1985 143 402-406. 13. Moller JE, Helweg J, Jacobson E. Histopathological lesions in the sciatic nerve of the rat following perineural application of phenol and alcohol solutions. Dan Med Bull 1969 16 116-119.
ESI is commonly used for relief of upper and lower back pain secondary to spinal stenosis, disc herniation with or without radicular pain, and refractory back pain of unknown etiology. ESI may help delay or prevent surgical treatment because many patients receive pain relief that allows them to endure an acute exacerbation of pain. ESI when combined with physical therapy and antiin-flammatory medications can provide satisfactory pain relief in patients who are not surgical candidates.
The frequency of administration is variable between institutions and specific patient requirements. Acute painful conditions may require daily lumbar epidural nerve blocks with both local anesthetics and steroids (35). Lumbar radiculopathy and diabetic neuropathy are examples of chronic pain syndromes treated on various schedules, from every other day, to once a week, to every few weeks, and are dictated by the results and the patient's clinical status.
In 1996, Schellhas et al. conducted a retrospective study of patients until records of 100 HIZ discs in 63 patients were found. Eighty-seven of the 100 discs tested were found to be concordantly painful. All 87 showed annular tears to the outer third of the annulus fibrosus. Of the 67 non-HIZ discs studied, 64 were nonconcordant. Schellhas concluded that in patients with symptomatic lower back pain, the HIZ is a reliable marker of painful outer annular disruption (13).
Posterior thighs, but unlike sciatica, rarely extends below the knee. Local palpation over the sacroiliac joints is often unhelpful and may give rise to false positive and false negative results. Stressing the pelvis may produce buttock pain if these joints are inflamed.
Epidural injections have been used in the management of neck and back pain for almost 100 yr, although they still remain quite controversial. The first reported epidural injection for pain management was in 1901 in Paris. M. A. Sicard injected cocaine for the treatment of sciatica (26). The description of the paramidline approach to the lumbar epidural space was proposed by Pag s in 1921 (27). Pag s' technique used the tactile feedback from the needles touching and passing through the ligamentum flavum as a means of identifying the epidural space. Confirmation of needle placement in the epidural space was based on absence of free flow of spinal fluid from the needle and the lack of resistance to injection of local anesthetic (27). This approach was technically demanding and was associated with a significant failure rate. Forestier and Sicard advocated attaching a fluid-filled syringe to a needle and injecting continuously while advancing the needle through the ligaments of the spine...
Sacral stress fractures may present as low back or buttock pain, mimicking disk disease, sciatica, or sacroiliac joint pathology. These fractures more commonly affect the female runner there are reports of adolescent female runners who had low back pain subsequently being diagnosed with sacral stress fractures
Yates compared the results of epidural injections of local anesthetic with and without the use of steroids.21 In this prospective double-blind study, patients with sciatica who received both the steroid and local anesthetics showed significant improvement at 1-month and 1-year follow-up, compared with those who received placebo.15 A double-blinded randomized control study by Ridley demonstrated short-term benefits in 39 outpatient sciatica pain sufferers. Patients receiving the injections showed significantly diminished rest and walking pain at 1 to 2 weeks following injection, compared with those who received placebo injections.28 Dilke and colleagues published a double-blind
MRI study of the upper extremity is routinely performed using dedicated phase-array coils, with the patient in a supine position and the arm by the side. The nerves of the upper extremity are in general best visualized on axial images. T1-weighted sequences provide superb anatomical resolution. Watersensitive sequences such as fat-suppressed T2-weighted and Short-tau inversion recovery (STIR) sequences are useful in identifying signs of neuritis neuropathy and acute denervation muscle injury. Acute axonal nerve lesions are manifested by T2 hyperintensity and increased girth of the nerve at and distal to the site of injury. Proximal increased girth may also be encountered. Increased T2 signal and post-gadolinium enhancement of denervated muscle fibers is most likely related to fluid shift from intracellular to extracellular compartment, and changes in the intramuscular vascular bed leading to capillary engorgement and increased muscular blood volume 5,6 . These changes were noted as...
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