Reduction in leg pain and lower-extremity weakness with Oxiplex/SP Gel for 1 year after laminectomy, laminotomy, and discectomy

Object Although good surgical technique is effective in reducing postoperative epidural fibrosis, compression or tethering of the nerve root may cause recurrent radicular pain and physical impairment. The implantation of a bioresorbable gel on the dura may further decrease the amount of scar formation after surgery and thus improve the patient's ability to perform activities of daily living (ADL). This study is a 12-month evaluation of the safety and effectiveness of Oxiplex/SP Gel (FzioMed, Inc., San Luis Obispo, CA) in the reduction of pain and radiculopathy after lumbar discectomy. Methods A pilot randomized single-blind multicenter clinical trial was conducted to evaluate the performance of Oxiplex/SP Gel in patients who underwent surgery for unilateral herniation of the lumbar disc at L4–5 or L5–S1. Eighteen patients with severe leg pain and lower-extremity weakness (11 women and seven men) were randomly assigned intraoperatively to receive the gel at the conclusion of surgery (treatment group) or to undergo surgery alone (control group). Self-assessment questionnaires (Lumbar Spine Outcomes Questionnaire) to assess pain, symptoms, and ADL were completed preoperatively and at scheduled postoperative intervals (30 days, 90 days, 6 months, and 12 months). The authors examined the spine and lower extremities of patients scheduled for discectomy to assess neurological function and pain. Treated patients received sufficient Oxiplex/SP Gel (1–3 ml) to coat the nerve root and fill the epidural space. Postoperative clinical evaluations were performed at 30 and 90 days. Patients completed the self-assessment questionnaires at baseline and were contacted by telephone or mail for the completion of the postoperative self-assessment questionnaires. Surgical procedures were well tolerated; no device-related adverse events and no clinically significant laboratory results were reported. The 11 patients with severe leg pain and lower-extremity weakness who were treated with Oxiplex/SP Gel had a reduction in those symptoms at 30 days, 90 days, 6 months, and 12 months after discectomy, compared with the seven control patients who underwent surgery only. Conclusions Oxiplex/SP Gel was easy to use and safe in patients who underwent unilateral discectomy. A greater benefit in clinical outcome measures was seen over the 12-month follow-up period in gel-treated patients.

Download Full-text

Hypertrophic Neuropathy of the Cauda Equina: Case Report

Neurosurgery ◽

10.1227/01.neu.0000103492.19663.ef ◽

2004 ◽

Vol 54 (2) ◽

pp. 515-519 ◽

Cited By ~ 11

Author(s):

Ryan M. Kretzer ◽

Peter C. Burger ◽

Rafael J. Tamargo

Keyword(s):

Lower Extremity ◽

Nerve Root ◽

Clinical Presentation ◽

Cauda Equina ◽

Radicular Pain ◽

Demyelinating Polyneuropathy ◽

Sensory Loss ◽

Pathological Examination ◽

Lower Extremity Weakness ◽

Hypertrophic Neuropathy

Abstract OBJECTIVE AND IMPORTANCE Hypertrophic neuropathy of the cauda equina (HNCE) is a rare form of peripheral neuropathy. The diagnosis is complicated by an insidious clinical presentation and complex radiographic images. We present a case of HNCE caused by chronic inflammatory demyelinating polyneuropathy with symptomatic improvement after decompressive lumbar laminectomy and dural expansion. CLINICAL PRESENTATION A 54-year-old woman with a history of back pain since she was in her 20s presented with low back and radicular pain that had increased during a period of 6 months, bilateral lower-extremity weakness, and sensory loss in the right thigh. Magnetic resonance imaging of the lumbosacral spine revealed multiple, poorly enhancing mass lesions and apparent intrathecal nerve root thickening from L1 to L5. INTERVENTION An L1-L5 decompressive laminectomy, performed with continuous somatosensory evoked potential and electromyographic monitoring, revealed multiple segmentally enlarged nerve roots. One nerve root that did not respond to high levels of stimulation was identified. This root was resected and submitted for pathological analysis. The dura was expanded with an 11-cm-long dural patch. The pathological examination revealed hypertrophic neuropathy, with extensive S-100-positive “onion bulb” formation. The patient's symptoms improved postoperatively. CONCLUSION HNCE is a rare disorder that can cause radicular pain and lower-extremity weakness, sensory loss, and hyporeflexia. One possible cause is demyelinating polyneuropathy. Although medical management is typically effective in the treatment of demyelinating polyneuropathy, it has little effect on compressive symptoms caused by intradural nerve root enlargement. As this case demonstrates, surgical management of symptomatic radiculopathy by lumbar laminectomy is a reasonable and effective approach to the treatment of HNCE.

Download Full-text

Feasibility of Using Intraoperative Neuromonitoring in the Prophylaxis of Dysesthesia in Transforaminal Endoscopic Discectomies of the Lumbar Spine

Brain Sciences ◽

10.3390/brainsci10080522 ◽

2020 ◽

Vol 10 (8) ◽

pp. 522

Author(s):

Paulo Sérgio Teixeira de Carvalho ◽

Max Rogério Freitas Ramos ◽

Alcy Caio da Silva Meireles ◽

Alexandre Peixoto ◽

Paulo de Carvalho ◽

...

Keyword(s):

Nerve Root ◽

Statistical Power ◽

Motor Evoked Potentials ◽

Lumbar Disc ◽

Intraoperative Neurophysiological Monitoring ◽

Neurophysiological Monitoring ◽

Control Group ◽

Nerve Root Injury ◽

Root Injury ◽

Sensory Evoked

(1) Background: Postoperative nerve root injury with dysesthesia is the most frequent sequela following lumbar endoscopic transforaminal discectomy. At times, it may be accompanied by transient and rarely by permanent motor weakness. The authors hypothesized that direct compression of the exiting nerve root and its dorsal root ganglion (DRG) by manipulating the working cannula or endoscopic instruments may play a role. (2) Objective: To assess whether intraoperative neurophysiological monitoring can help prevent nerve root injury by identifying neurophysiological events during the initial placement of the endoscopic working cannula and the directly visualized video endoscopic procedure. (3) Methods: The authors performed a retrospective chart review of 65 (35 female and 30 male) patients who underwent transforaminal endoscopic decompression for failed non-operative treatment of lumbar disc herniation from 2012 to 2020. The patients’ age ranged from 22 to 86 years, with an average of 51.75 years. Patients in the experimental group (32 patients) had intraoperative neurophysiological monitoring recordings using sensory evoked (SSEP), and transcranial motor evoked potentials (TCEP), those in the control group (32 patients) did not. The SSEP and TCMEP data were analyzed and correlated to the postoperative course, including dysesthesia and clinical outcomes using modified Macnab criteria, Oswestry disability index (ODI), visual analog scale (VAS) for leg and back pain. (4) Results: The surgical levels were L4/L5 in 44.6%, L5/S1 in 23.1%, and L3/L4 in 9.2%. Of the 65 patients, 56.9% (37/65) had surgery on the left, 36.9% (24/65) on the right, and the remaining 6.2% (4/65) underwent bilateral decompression. Postoperative dysesthesia occurred in 2 patients in the experimental and six patients in the control group. In the experimental neuromonitoring group, there was electrodiagnostic evidence of compression of the exiting nerve root’s DRG in 24 (72.7%) of the 32 patients after initial transforaminal placement of the working cannula. A 5% or more decrease and a 50% or more decrease in amplitude of SSEPs and TCEPs recordings of the exiting nerve root were resolved by repositioning the working cannula or by pausing the root manipulation until recovery to baseline, which typically occurred within an average of 1.15 min. In 15 of the 24 patients with such latency and amplitude changes, a foraminoplasty was performed before advancing the endoscopic working cannula via the transforaminal approach into the neuroforamen to avoid an impeding nerve root injury and postoperative dysesthesia. (5) Conclusion: Neuromonitoring enabled the intraoperative diagnosis of DRG compression during the initial transforaminal placement of the endoscopic working cannula. Future studies with more statistical power will have to investigate whether employing neuromonitoring to avoid intraoperative compression of the exiting nerve root is predictive of lower postoperative dysesthesia rates in patients undergoing videoendoscopic transforaminal discectomy.

Download Full-text

Spinal PAR1 RNA Levels Are Regulated by Mechanical and Inflammatory Cues in Painful Nerve Root Compression

ASME 2011 Summer Bioengineering Conference, Parts A and B ◽

10.1115/sbc2011-53084 ◽

2011 ◽

Author(s):

Jenell R. Smith ◽

Sarah M. Rothman ◽

Paul A. Janmey ◽

Beth A. Winkelstein

Keyword(s):

Disc Herniation ◽

Nerve Root ◽

Inflammatory Responses ◽

Radicular Pain ◽

Spinal Nerve ◽

Chemical Components ◽

Biochemical Processes ◽

Pain Models ◽

Pain Symptoms ◽

Type Of Injury

Radicular pain can be caused by a disc herniation that can compress the spinal nerve roots as they exit the spinal canal [1]. Pain models in the rat mimic both the mechanical and chemical components of a disc herniation, either individually or in combination, and have demonstrated that the specific injury inputs (i.e. mechanics, inflammation) modulate the pain responses [2,3]. For both types of nerve root injuries, allodynia (i.e. pain) is elevated as early as 1 day after injury but its temporal responses vary over time according to the type of injury insult [3]. Painful nerve root injuries also induce a host of inflammatory cascades in the spinal cord that promote neuronal healing [2–4]. Although inflammatory responses have been shown to relate to the onset and maintenance of pain following injury, the specific biochemical processes and their relationship to inflammation and pain symptoms are not yet fully defined.

Download Full-text

Diagnosis of Intermittent Vascular Claudication in a Patient With a Diagnosis of Sciatica

Physical Therapy ◽

10.1093/ptj/79.6.582 ◽

1999 ◽

Vol 79 (6) ◽

pp. 582-590 ◽

Cited By ~ 13

Author(s):

John C Gray

Keyword(s):

Case Report ◽

Lower Extremity ◽

Signs And Symptoms ◽

Leg Pain ◽

Musculoskeletal Symptoms ◽

Medical Screening ◽

Medical Problems ◽

Lower Extremity Weakness ◽

Screening Questionnaire ◽

Rule Out

Abstract Background and Purpose. The purpose of this case report is to illustrate the importance of medical screening to rule out medical problems that may mimic musculoskeletal symptoms. Case Description. This case report describes a woman who was referred with a diagnosis of sciatica but who had signs and symptoms consistent with vascular stenosis. The patient complained of bilateral lower-extremity weakness with her pain intensity at a minimal level in the region of the left sacroiliac joint and left buttock. She also reported numbness in her left leg after walking, sensations of cold and then heat during walking, and cramps in her right calf muscle. She did not report any leg pain. A medical screening questionnaire revealed an extensive family history of heart disease. Examination of the lumbar spine and nervous system was negative. A diminished dorsalis pedis pulse was noted on the left side. Stationary cycling in lumbar flexion reproduced the patient's complaints of lower-extremity weakness and temporarily abolished her dorsalis pedis pulse on the left side. Outcomes. She was referred back to her physician with a request to rule out vascular disease. The patient was subsequently diagnosed, by a vascular specialist, with a “high-grade circumferential stenosis of the distal-most aorta at its bifurcation.” Discussion. This case report points out the importance of a thorough history, a medical screening questionnaire, and a comprehensive examination during the evaluation process to rule out medical problems that might mimic musculoskeletal symptoms.

Download Full-text

Unilateral surgical approach for lumbar disc herniation with contralateral symptoms

Journal of Neurosurgery Spine ◽

10.3171/2012.4.spine11365 ◽

2012 ◽

Vol 17 (2) ◽

pp. 124-127 ◽

Cited By ~ 5

Author(s):

Taşkan Akdeniz ◽

Tuncay Kaner ◽

İbrahim Tutkan ◽

Ali Fahir Ozer

Keyword(s):

Lumbar Disc Herniation ◽

Disc Herniation ◽

Surgical Approach ◽

Lumbar Disc ◽

Radicular Pain ◽

Leg Pain ◽

Motor Deficits ◽

Disc Herniations ◽

Herniated Lumbar Disc ◽

Contralateral Symptoms

Object In most cases of lumbar disc herniation, the primary problem is usually limited to radicular pain due to nerve compression on the herniated side, which is generally limited to the side of operation. The aim of this study was to reevaluate the side of the surgical approach in a selected group of patients with leg pain and contralateral lumbar disc herniation. Methods Included in this study were a total of 5 patients with lumbar disc herniations who presented with contralateral symptoms and neurological signs. In all cases, patients underwent a microdiscectomy from the side ipsilateral to the herniated lumbar disc, the side contralateral to the motor deficits and leg pain. Results The symptoms and signs, to some extent, resolved during the immediate postoperative period. There were no postoperative complications. Conclusions The findings confirm that performing a laminotomy via the side of the herniation is sufficient for this group of patients.

Download Full-text

Where do patients with MRI-confirmed single-level radiculopathy experience pain, and what is the clinical interpretability of these pain patterns? A cross-sectional diagnostic accuracy study

Chiropractic & Manual Therapies ◽

10.1186/s12998-019-0273-8 ◽

2019 ◽

Vol 27 (1) ◽

Cited By ~ 1

Author(s):

Hanne B. Albert ◽

Jeanette Kaae Hansen ◽

Helle Søgaard ◽

Peter Kent

Keyword(s):

Diagnostic Accuracy ◽

Nerve Root ◽

Radicular Pain ◽

Leg Pain ◽

Nerve Root Compression ◽

Diagnostic Accuracy Study ◽

Nerve Roots ◽

Cross Sectional ◽

Single Level ◽

Accuracy Study

Abstract Background Clinicians nominate the distribution of leg pain as being important in diagnosing nerve root involvement. This study aimed to identify: (i) common unisegmental radicular pain patterns and whether they were dermatomal, and (ii) whether these radicular pain patterns assisted clinician discrimination of the nerve root level involved. Methods A cross-sectional diagnostic accuracy study of adult patients with radicular leg pain at a hospital in Denmark. All patients had positive neurological signs (average 2.8 signs - hypoalgesia, diminished reflexes, muscle weakness, positive Straight Leg Raise test). Part 1 (pain patterns) was a secondary analysis of baseline pain pattern data collected during a clinical trial. The pain charts of 93 patients with an MRI and clinically confirmed single-level disc herniation with nerve root compression were digitised and layered to form a composite picture of the radicular patterns for the L5 and S1 nerve roots, which were then compared to published dermatomes. In Part 2 (clinical utility) we prospectively measured the discriminative ability of the identified pain patterns. The accuracy was calculated of three groups of six clinicians at classifying the nerve root affected in a randomized sequence of 53 patients, when not shown, briefly shown or continuously shown the composite pain patterns. In each group were two chiropractors, two medical doctors and two physiotherapists. Results There was a wide overlap in pain patterns from compromised L5 and S1 nerve roots but some distinguishing features. These pain patterns had approximately 50 to 80% overlap with published dermatomes. Clinicians were unable to determine with any accuracy above chance whether an individual pain drawing was from a person with a compromised L5 or S1 nerve root, and use of the composite pain drawings did not improve that accuracy. Conclusions While pain distribution may be an indication of radiculopathy, pain patterns from L5 or S1 nerve root compression only approximated those of sensory dermatomes, and level-specific knowledge about radicular pain patterns did not assist clinicians’ diagnostic accuracy of the nerve root impinged. These results indicate that, on their own, pain patterns provide very limited additional diagnostic information about which individual nerve root is affected.

Download Full-text

Functional outcome of microscopic lumbar discectomy for the treatment of lumbar disc prolapse

International Journal of Research in Orthopaedics ◽

10.18203/issn.2455-4510.intjresorthop20181438 ◽

2018 ◽

Vol 4 (3) ◽

pp. 389

Author(s):

Ansari Ishtyaque Abdul Aziz ◽

Ansari Muqtadeer Abdul Aziz

Keyword(s):

Back Pain ◽

Lumbar Disc ◽

Japanese Orthopaedic Association ◽

Significant Proportion ◽

Scientific Basis ◽

Radicular Pain ◽

Lumbar Discectomy ◽

Leg Pain ◽

Disc Prolapse ◽

Lumbar Disc Prolapse

Background: Back pain constitutes significant proportion of orthopaedic practitioner OPD. Lumbar disc prolapse constitutes important cause of back pain with radiculopathic leg pain. Different techniques have evolved to treat this disorder non-operatively and operatively. Operative techniques vary a lot in the field of spine surgery depending on the surgeon, institute, infrastructure and cost. We present simple, cost effective, cosmetic, operative technique with scientific basis which gives better visualization for decompression of nerve root in this paper called microscopic lumbar discectomy (MLD).Methods: On the basis of inclusion and exclusion criteria 26 patients were operated by microscopic lumbar discectomy (MLD) technique. All the patients were followed up at the interval of 1 month, 3 months and 6 months and assessment was done of subjective and objective findings with Japanese orthopaedic association (JOA) score and rate of improvement (RI) was calculated. Out of 26 patients 18 were men and 8 were women. Age ranges from 28 years to 72 years. Mean age being 47.8 years.Results: Out of 26 patients at the time of discharge, 20 patients (87.5%) could walk independently without any aid and without any radicular pain. In most of the patients 19 (73.07%) sciatica improved immediately. The pre-operative mean±SD (SE) JOA score was 8.346±0.85 (0.169) which improved to 11.807±0.694 (0.136) after 1 month and 13.19±0.895 (0.175) after 6 months.Conclusions: Excellent to good results and improvement can be achieved surgically, economically and cosmetically by microscopic lumbar discectomy technique in the spine lumbar disc prolapse patients at many spine centre with cosmesis, good results and rehabilitation of the patient.

Download Full-text

Lumbar Epidural Metastasis of Breast Cancer Resembling Lumbar Disc Herniation

10.21203/rs.3.rs-648479/v1 ◽

2021 ◽

Author(s):

Takanori Fukunaga ◽

Masao Umegaki ◽

Yohei Bamba ◽

Yasuaki Tsuchida ◽

Koshi Ninomiya ◽

...

Keyword(s):

Breast Cancer ◽

Lumbar Disc Herniation ◽

Disc Herniation ◽

Nerve Root ◽

Lumbar Disc ◽

Metastatic Lesion ◽

Surgical Decompression ◽

Leg Pain ◽

Pathological Examination ◽

Epidural Metastasis

Abstract A 49-year-old woman who had breast cancer suffered from left leg pain. Initial MRI indicated lumbar disc herniation compressing S1 nerve root. The pain was uncontrollable with conservative treatments and she underwent surgical decompression. Intraoperative findings showed that left S1 nerve root was compressed by soft and gray tumor locating ventrally. We resected the tumor and S1 nerve root was adequately decompressed. Bone tissue around the tumor was intact, and there was no finding of bone metastasis. Pathological examination demonstrated adenocarcinoma as same as original breast cancer. We should constantly consider differential diagnosis as metastatic lesion in case of malignancy.

Download Full-text

Cauda Equina Syndrome

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2000.janfeb01 ◽

2000 ◽

Vol 5 (1) ◽

pp. 1-2

Author(s):

Leon H. Ensalada

Keyword(s):

Lower Extremity ◽

Cauda Equina Syndrome ◽

Cauda Equina ◽

Leg Pain ◽

Lower Extremity Function ◽

Lower Extremity Weakness ◽

Injury Model ◽

History Of ◽

Radicular Syndrome ◽

Lumbar Spinal

Abstract The cauda equina is a collection of peripheral nerves in the common dural sheath within the lumbar spinal canal. Cauda equina syndrome, also known as bilateral acute radicular syndrome, usually is caused by a large, sequestered acute disc rupture at L3-4, L4-5, or L5-S1 that produces partial or complete lesions of the cauda equina–lower motor neuron lesions associated with flaccid paralysis, atrophy, and other conditions. Patients usually present with a history of back symptoms that have worsened precipitously. The syndrome includes back pain, bilateral leg pain, saddle anesthesia, bilateral lower extremity weakness, urinary bladder retention, and lax rectal tone. Cauda equina syndrome is rated using Diagnosis-related estimates (DRE) lumbosacral categories VI or VII. Category VI, Cauda Equina–like Syndrome Without Bowel or Bladder Signs, is used when there is permanent bilateral partial loss of lower extremity function but no bowel or bladder impairment. Category VII, Cauda Equina Syndrome with Bowel or Bladder Impairment, is similar to Category VI but also includes bowel or bladder impairment. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) uses the term cauda equina syndrome with reference to both the thoracolumbar and cervicothoracic spine regions; this usage is unique to the AMA Guides but maintains the internal consistency of the Injury Model, which is the best approach to date for assessing spine impairment.

Download Full-text

Intraoperative Measurements of Nerve Root Tension During Posterior Lumbar Interbody Fusion

10.21203/rs.3.rs-1098798/v1 ◽

2021 ◽

Author(s):

Zhi-yi Fu ◽

Yujie Wu ◽

Tong Zhu

Keyword(s):

Nerve Root ◽

Interbody Fusion ◽

Lumbar Disc ◽

Posterior Lumbar Interbody Fusion ◽

Leg Pain ◽

Lumbar Interbody Fusion ◽

Important Indicator ◽

Vas Score ◽

Before And After ◽

Vas Scores

Abstract Background There is no effective standard method to evaluate whether the nerve root tension is restored, which is an important indicator for the recovery of nerve function. This study aimed to demonstrate a technique for measuring nerve root tension during surgery. Methods A total of 54 consecutive patients (average age, 52.3 years; range, 28-68 years) received posterior lumbar interbody fusion for lumbar disc herniation comprised the patient sample.The nerve root tension was measured twice before and after intraoperative decompression by the nerve root tension meter modified from the transverse gauge by author. Clinical outcome was assessed by the visual analog scale (VAS) for leg pain, provided by patients before and after surgery. Results There was a significant improvement in the VAS score for leg pain after surgery compared with that before surgery (7.0 ± 2.24 vs. 0.8 ± 0.84, respectively; P < 0.01). Nerve root tension was significantly decreased after decompression compared with that before surgery (1.32 ± 0.22 N vs. 0.64 ± 0.17 N, respectively; P < 0.01). The nerve root tension was positively correlated with the VAS score (r = 0.772, P < 0.05; r = 0.715, P < 0.05). Conclusions This study shows that the nerve root tension meter can instantly and non-invasively measure nerve root tension during an operation. It was demonstrated that the nerve root tension of the patient is significantly reduced after decompression. Meanwhile, the VAS score improved significantly, and the nerve root tension and VAS scores were positively correlated.

Download Full-text