Quadriceps weakness due to disc protrusion causing nerve root compression. A case report and literature review

Most common presentation of spinal disc herniation is pain. Next common presentation is pain associated with neurological symptoms [1] . It is relatively unusual to present muscular weakness purely due to disc herniation in the absence of lower back or neuropathic pain and can be a diagnostic challenge. A male patient of 45 presented to his family physician with five days history of weakness in the left quadriceps. There was no pain in the back or leg or any sensory symptoms at this stage. There was no other significant past medical history apart of history of spontaneous disc prolapse when he was 26. (radiating pain to the left leg but no neurological symptoms at that time). Clinical examination revealed motor deficit of 4/5 in the left quadriceps and diminished knee reflex. There was no sensory deficit elicited at this stage. Patient was referred to neurologist (by this time patient had developed sensory deficit at medial lower leg) who arranged nerve conduction studies which revealed L4 radiculopathy. Patient was referred to spinal surgeon who after consultation arranged MRI of the lumbosacral spine which showed disc extrusion at L3-4 level causing root compression of L4 nerve root. Since the patient was active sportsman, it was decided to do discectomy. However, after case discussion in spinal team meeting, (and patient started to feel slight improvement in sensory symptoms after couple of weeks) it was decided to manage conservatively. Patient started physiotherapy for three months and gradually noticed complete resolution of sensory loss after a month and gradual improvement in motor weakness. Patient started light sporting activities after three months of orthopaedic consultation. Patient continued to recover and had complete resolution of motor symptoms within a year. Patient had a follow up MRI after about a year which showed subtle improvement of compression at the same level. Patient was discharged from outpatient follow up. This case illustrates diagnostic dilemma when symptoms are not typical. However, it is proven the ‘common things are common’ again. Conservative management seems to be way forward when neurological symptoms are mild especially in the absence of neuropathic pain, However, it needs to be decided on case-by-case basis

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Surgical treatment of laterally ruptured cervical disc

Journal of Neurosurgery ◽

10.3171/jns.1973.38.6.0679 ◽

1973 ◽

Vol 38 (6) ◽

pp. 679-683 ◽

Cited By ~ 92

Author(s):

Francis Murphey ◽

James C. H. Simmons ◽

Bruce Brunson

Keyword(s):

Nerve Root ◽

Cervical Disc ◽

Root Pressure ◽

Content Type ◽

Arm Pain ◽

Follow Up Study ◽

History Of ◽

Neurosurgical Operation ◽

Better Than

✓ From the analysis of 648 patients operated on for ruptured cervical discs between 1939 and March of 1972 and a follow-up study of 380 of these patients, the following conclusions seem justified. Osteophytes or hypertrophic spurs rarely produced the classical clinical picture or deficits. Ninety per cent of the patients awakened in the morning with pain in the neck and rhomboid region. Ten per cent had a history of injury, but there was no characteristic pattern as in lumbar discs. Only one patient had a typical hyperextension injury. Anterior chest pain occurred in one-fifth of the cases. Pain in the neck, rhomboid region, and anterior chest was referred from the discs, while the arm pain was usually the result of nerve root compression; however, in a few cases the degenerating disc caused referred pain to the arm without any nerve root pressure. Since accurate diagnosis can be made on clinical grounds, myelography is not necessary in most cases. In our experience conservative treatment was usually unsuccessful while the surgical results were better than in almost any other neurosurgical operation. The nerve root syndromes associated with extruded lateral cervical discs are outlined and the indications and contraindications for myelography discussed.

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Migratory non-itchy rash

Journal of Clinical Images and Medical Case Reports ◽

10.52768/2766-7820/1282 ◽

2021 ◽

Vol 2 (4) ◽

Author(s):

Sami Hoshi ◽

Keyword(s):

Physical Examination ◽

Complete Resolution ◽

Endemic Region ◽

The West ◽

Western Blot Test ◽

Joint Tenderness ◽

Mucous Membranes ◽

The Usa ◽

History Of

A 58-year-old man presented with 4-day history of multiple, erythematous, non-itchy, painless, patchy spots, along with fatigue and jaw pain. This rash started around the periumbilical area and then spread over his chest and right upper back (Figure 1,2). There was no involvement of face, mucous membranes, and extremities. He denied any sore throat, cough, or other symptoms. Besides the skin rash, his physical examination was unremarkable. There was no temporomandibular joint swelling, or joint tenderness. A month ago, he travelled along with the west coast of Michigan – a Lyme-endemic region of the USA and noted his exposure to mosquitoes. Shortly after his visit, he recalled having fever, chills, myalgia and a similar patchy groin rash which resolved in a few days. At that time, blood work by his family physician revealed mild transaminitis. At the current visit, repeat blood work and electrocardiogram were normal. A clinical diagnosis of early disseminated Lyme disease was made. Lyme Ab IgM and IgG were both elevated, as was his Western blot test. He was given a 10-day course of doxycycline. He reported complete resolution of his symptoms at follow up.

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Unilateral Neuroimaging Findings in Pediatric Craniofacial Scleroderma: Parry-Romberg Syndrome and En Coup de Sabre

Journal of Child Neurology ◽

10.1177/0883073820931253 ◽

2020 ◽

Vol 35 (11) ◽

pp. 753-762

Author(s):

Ronald R. Seese ◽

Daniel Glaser ◽

Andre Furtado ◽

Kavita Thakkar ◽

Kathryn S. Torok

Keyword(s):

Central Nervous System ◽

Nervous System ◽

White Matter ◽

Neurological Symptoms ◽

Localized Scleroderma ◽

Imaging Findings ◽

History Of ◽

Parry Romberg Syndrome ◽

Clinical Associations

Objective: Parry-Romberg syndrome (PRS) and en coup de sabre (ECDS) are subtypes of craniofacial localized scleroderma. Systematic analyses of central nervous system imaging findings and their clinical associations in children are lacking. Here, we aim to characterize neuroimaging findings and associated neurological symptoms in these conditions. Methods: Neuroimaging and neurological symptoms of children evaluated at our institution with a diagnosis of PRS or ECDS were retrospectively reviewed. Laterality, location, stability, and number of lesion(s) were evaluated, as was the presence of susceptibility lesion(s) and contrast enhancement. History of seizures or headaches was noted. Results: From 2003 to 2019, 80 patients with PRS or ECDS were followed at our institution. Neuroimaging was completed in 73 and found to be abnormal in 25. In 12 (48%) of these 25 cases, headaches and/or seizures were present. In the vast majority of these cases (22/25, 88%), lesions were ipsilateral to skin findings. White matter was involved in 19 (76%) patients. MRI abnormalities preceded a rheumatological diagnosis in 7 (28%). Susceptibility lesions were noted in 11 (44%), and 8 (73%) of these patients endorsed a history of headaches. Most lesions were in the supratentorial compartment, did not enhance, and were stable at 1-year follow up imaging. Of those with progression, susceptibility findings were present at baseline. Conclusions: Neuroimaging findings in pediatric PRS and ECDS are often supratentorial, stable, unilateral, and ipsilateral to skin findings, and they can precede cutaneous findings.

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A Phalangeal Osteoid Osteoma: A Case Report

Pulse ◽

10.3329/pulse.v8i1.28105 ◽

2016 ◽

Vol 8 (1) ◽

pp. 69-72

Author(s):

Syed Khalequezzaman ◽

Biva Shrestha Khan ◽

Bidyut K Saha ◽

Pankaj Kumar

Keyword(s):

Osteoid Osteoma ◽

Complete Resolution ◽

Surgical Excision ◽

Middle Finger ◽

Definitive Diagnosis ◽

Important Differential Diagnosis ◽

Local Doctor ◽

History Of ◽

Uncommon Condition

Osteoid osteoma is a benign bone forming tumor of the growing skeleton that is most often seen in young men. It represents by pain and radiologic appearance of a nidus surrounded by osteosclerosis that occurs mostly in long bones of the lower extremity. Occurrence of this tumor in the hand is an uncommon condition. A 35 year old right-hand-dominant man presented to our orthopedic and trauma OPD with an approximately 2 year history of right middle finger pain without any history of trauma. He consulted previously with a local doctor and had undergone xray of the hand with no definitive diagnosis. Computed tomography at our institution was consistent with the diagnosis of osteoid osteoma. The patient was treated with surgical excision of the lesion without bone grafting. The diagnosis of osteoid osteoma was confirmed by histopathology. Follow up visit showed complete resolution of pain. In this case demonstrating that osteoid osteoma is an important differential diagnosis in patients with finger pain.Pulse Vol.8 January-December 2015 p.69-72

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Outcome of Conservative Management in Biliary Ascariasis - A Study of 98 Cases

Journal of Dhaka Medical College ◽

10.3329/jdmc.v19i1.6247 ◽

1970 ◽

Vol 19 (1) ◽

pp. 25-28 ◽

Cited By ~ 2

Author(s):

AS Khan ◽

B Bhowmik ◽

HAN Hakim ◽

MA Islam

Keyword(s):

Abdominal Pain ◽

Conservative Management ◽

Diagnostic Tools ◽

Biliary Disease ◽

Common Presentation ◽

Biliary Ascariasis ◽

Clinical Presentations ◽

History Of ◽

Upper Abdominal

Objectives: History of ascariasis is very old. One quarter of the world's population is known to be infected by ascariasis. It is endemic in various parts of Bangladesh. We aimed to study the various types of clinical presentations, complications and different diagnostic tools and to assess various options for the management of biliary ascariasis. Materials and Methods: Ninty eight cases of hepatobiliary ascariasis were studied over a period of 2 years (April 03 - April 05). All the patients were aged between 12 and 73 years and all were admitted with acute right upper abdominal pain. Ultrasound was the diagnostic tool of choice with 100% results. Results: In this study, biliary ascariasis was found to be more common in females 64.29% (64 patients). The most common presentation was upper abdominal pain in 100% of the patients (98 patients). Complications observed were obstructive jaundice in 08.16% (8 patients), cholangitis in 74.49% (73 patients). History of worm emesis was present in 21.42% (21 patients). Conservative management was successful in 96.94% (95 patients). During follow-up, worm reinvasion of the biliary system occurred in 7.1% (three patients). Conclusion: In endemic countries, biliary ascariasis should be suspected in patients with biliary disease. Most of the patients respond to conservative management. Keywords: Acute upper abdominal pain; biliary ascariasis; Ultrasonography DOI: 10.3329/jdmc.v19i1.6247 J Dhaka Med Coll. 2010; 19(1) : 25-28.

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Dermatomyotomal supply in patients with variations in the number of lumbar vertebrae

Journal of Neurosurgery Spine ◽

10.3171/2009.9.spine09114 ◽

2010 ◽

Vol 12 (3) ◽

pp. 314-319 ◽

Cited By ~ 4

Author(s):

Michael Kottlors ◽

Franz Xaver Glocker

Keyword(s):

Disc Herniation ◽

Nerve Root ◽

Lumbar Vertebrae ◽

Lumbar Vertebra ◽

Motor Deficit ◽

Sacral Vertebra ◽

Imaging Data ◽

Nerve Roots ◽

Lumbar Nerve Root ◽

Electrophysiological Examination

Object Variation in the number of lumbar vertebrae occurs in a small portion of the population. Either the fifth lumbar vertebra shows assimilation to the sacrum or the first sacral vertebra shows a lumbar configuration, resulting in 4 or 6 lumbar vertebrae, respectively. Etiologically, lumbar nerve root syndrome is diagnosed by comparing the anatomical level of the disc herniation to the compressed nerve root and to the pattern of the peripheral sensory and motor deficit. In case of a variation in the number of lumbar vertebrae, defining the lumbar nerve roots becomes difficult. Variations in the number of lumbar vertebrae make the landmarks (the twelfth rib and the first sacral vertebra) unreliable clues to define the nerve roots. The allocation of the clinically damaged segment to the spinal disorder seen in imaging studies is essential for differential diagnosis and spine surgery. Methods A retrospective study was conducted of clinical, electrophysiological, and imaging data among inpatients over a period of 21 months. Eight patients who had isolated monosegmental discogenic nerve root compression and a variation in the number of lumbar vertebrae were selected. Results Seven patients presented with 6 lumbar vertebrae, and 1 patient presented with 4 lumbar vertebrae and disc herniation on 1 of the 2 caudal levels. Compression of the second-to-last nerve root in patients with 6 lumbar vertebrae resulted either in clinical L-5 or S-1 syndrome, or a combination of both. Compression of the last caudal nerve root resulted in a clinical S-1 nerve root syndrome. Conclusions The findings suggest that the dermatomyotomal supply of the lumbosacral nerve roots can vary in patients with a variation in the number of lumbar vertebrae, and a meticulous clinical, radiological, and electrophysiological examination is essential.

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Soft disc herniation in patients with lumbar stenosis

Neurosurgical FOCUS ◽

10.3171/foc.1997.3.2.13 ◽

1997 ◽

Vol 3 (2) ◽

pp. E12 ◽

Cited By ~ 1

Author(s):

Martin H. Savitz

Keyword(s):

Disc Herniation ◽

Neurogenic Claudication ◽

Lumbar Stenosis ◽

The Past ◽

Single Nerve ◽

History Of ◽

Narrow Spinal Canal ◽

Herniated Nucleus Pulposus ◽

Nerve Root Involvement

Over a period of 25 years, a surgical technique has evolved for removal of a soft disc herniation in patients with sciatica and lumbar stenosis demonstrated on neuroradiological studies. Initially emphasis was placed on decompression of the entire narrow spinal canal when there was evidence of single nerve root involvement and no history of neurogenic claudication. The author has performed 12 microsurgical discectomies since 1984 and eight percutaneous endoscopic discectomies over the past 6 years that have been successful in relieving radiculitis and radiculopathy in cases of a single herniated nucleus pulposus, even in the presence of a stenotic canal. No patient complained of generalized numbness, weakness, or pain in the lower extremities while walking. After at least 1 year of follow up, the 20 patients who underwent microsurgical or arthroscopic procedures limited to removing the ruptured disc have not required more extensive decompression.

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Clinical diagnosis of TIA or stroke and prognosis in patients with neurological symptoms: a rapid access clinic cohort

10.1101/507012 ◽

2018 ◽

Author(s):

William N Whiteley ◽

Catriona Graham ◽

David Bailey ◽

Simon Hart ◽

Aidan Hutchison ◽

...

Keyword(s):

Vascular Disease ◽

Clinical Diagnosis ◽

Haemorrhagic Stroke ◽

Neurological Symptoms ◽

Minor Stroke ◽

Late Time ◽

Rapid Access ◽

History Of ◽

Rapid Access Clinic

Background The long-term risk of stroke or MI in patients with minor neurological symptoms who are not clinically diagnosed with transient ischaemic attack (TIA) or minor stroke is uncertain. Methods We used data from a rapid access clinic for patients with suspected TIA or minor stroke and follow-up from four overlapping data sources for a diagnosis of ischaemic or haemorrhagic stroke, myocardial infarction, major haemorrhage and death. We identified patients with and without a clinical diagnosis of TIA or minor stroke. We estimated hazard ratios of stroke, MI and death in early and late time periods. Results 5,997 patients were seen from 2004–2013, who were diagnosed TIA or minor stroke (n=3604, 60%) or with other diagnoses (n=2392, 40%). By 5 years the proportion of patients who had a subsequent ischaemic stroke or MI, in patients with a clinical diagnosis of minor stroke or TIA was 19% [95% confidence interval (CI): 17–20%], and in patients with other diagnoses was 10% (95%CI: 8–15%). Patients with clinical diagnosis of TIA or minor stroke had three times the hazard of stroke or MI compared to patients with other diagnoses (HR 2.83 95%CI:2.13–3.76, adjusted age and sex) by 90 days post-event; however from 90 days to end of follow up, this difference was attenuated (HR 1.52, 95%CI:1.25–1.86). Older patients and those who had a history of vascular disease had a high risk of stroke or MI, whether or not they were diagnosed with minor stroke or TIA. Conclusions Careful attention to vascular risk factors in patients presenting with transient or minor neurological symptoms not thought to be due to stroke or TIA is justified, particularly those who are older or have a history of vascular disease.

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RARE-13. PRIMARY EMPTY SELLA SYNDROME AND PSEUDO-TUMOR CEREBERI: CORRELATION OF ASSOCIATION AND SURGICAL PLAN

Neuro-Oncology ◽

10.1093/neuonc/noab090.174 ◽

2021 ◽

Vol 23 (Supplement_1) ◽

pp. i43-i43

Author(s):

Mohamed Arnaout

Keyword(s):

Cerebrospinal Fluid ◽

Natural History ◽

Idiopathic Intracranial Hypertension ◽

Empty Sella ◽

Empty Sella Syndrome ◽

Common Presentation ◽

History Of ◽

The Relationship ◽

Primary Empty Sella

Abstract Introduction Management of primary empty sella syndrome (ESS) is generally remaining a neurosurgical challenge due to lack of a well standardized approach. Pseudo-tumor cereberi (Benign or idiopathic intracranial hypertension) is commonly associated condition. In this study, we have demonstrated the relationship and surgical plan and outcome of such cases. Patients and Methods: We retrospectively studied 24 patients with primary empty sella syndrome (ESS) for two years who were diagnosed radiologically as ESS. Fundus and other ophthalmological examinations were done. Lumbar puncture and cerebrospinal fluid (CSF) manometer were evaluated in those with papilledema. All patients’ data were collected and analyzed. Results Basically, 24 patients (18 females and 6 males) were radiologically diagnosed as EES. 13 females and only one male were having symptoms of BIH. 17 patients (70.83%) had headache as the first presentation. Second most common presentation in our study was visual in 14 patients (58.3%). Two patients (8.3%) had pituitary hypersecretion namely; growth and prolactin hormones. In those (58.3%) confirmed to have BIH Theco-peritoneal shunts were inserted. Incidental cases (29.17%) without symptoms were followed up. Conclusion Although (ESS) is a well-known radiological hallmark for BIH, in our study not all patients had BIH. Interestingly, pituitary hyperfunction may be the first presentation in some rare cases. Generally, natural history of that entity was benign. Frequent follow-up by neurosurgeons and increased awareness of associations are advised. We believe a more prospective large number cohort is important to outline the natural history.

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Sacral hemangioblastoma in a patient with von Hippel–Lindau disease

Neurosurgical FOCUS ◽

10.3171/foc.2003.15.2.11 ◽

2003 ◽

Vol 15 (2) ◽

pp. 1-4 ◽

Cited By ~ 13

Author(s):

Ryszard M. Pluta ◽

Scott D. Wait ◽

John A. Butman ◽

Kathleen A. Leppig ◽

Alexander O. Vortmeyer ◽

...

Keyword(s):

Nerve Root ◽

Histopathological Diagnosis ◽

Resonance Imaging ◽

Nerve Roots ◽

Von Hippel Lindau ◽

Sacral Nerve ◽

Left Lower Extremity ◽

History Of ◽

Von Hippel Lindau Disease

Hemangioblastomas are histologically benign neoplasms that occur sporadically or as part of von Hippel–Lindau disease. Hemangioblastomas may occur anywhere along the neuraxis, but sacral hemangioblastomas are extremely rare. To identify features that will help guide the operative and clinical management of these lesions, the authors describe the management of a large von Hippel–Lindau disease–associated sacral hemangioblastoma and review the literature. The authors present the case of a 38-year-old woman with von Hippel–Lindau disease and a 10-year history of progressive back pain, as well as left lower-extremity pain and numbness. Neurological examination revealed decreased sensation in the left S-1 and S-2 dermatomes. Magnetic resonance imaging demonstrated a large enhancing lesion in the sacral region, with associated erosion of the sacrum. The patient underwent arteriography and embolization of the tumor and then resection. The histopathological diagnosis was consistent with hemangioblastoma and showed intrafascicular tumor infiltration of the S-2 nerve root. At 1-year follow-up examination, pain had resolved and numbness improved. Sacral nerve root hemangioblastomas may be safely removed in most patients, resulting in stabilization or improvement in symptomatology. Generally, hemangioblastomas of the sacral nerve roots should be removed when they cause symptoms. Because they originate from the nerve root, the nerve root from which the hemangioblastoma originates must be sacrificed to achieve complete resection.

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