Outcome of Delayed Decompression Surgery for Cauda Equina Syndrome secondary to Lumbar Disc Herniation: A Case Report

@#Cauda equina syndrome (CES) is a constellation of symptoms which consist of low back pain, sciatica, saddlearea paraesthesia, urinary or faecal incontinence, with or without motor weakness, and sensory deficit. Surgical decompression is indicated as soon as possible, as decompression within 48 hours from onset allows maximum improvement of symptoms. Recovery usually occurs months or years postoperatively. We report a case of a patient with cauda equina syndrome secondary to massive lumbar disc herniation who had undergone urgent decompression one week after onset of urinary and bowel dysfunction. The clinical outcome post surgery was also discussed.

Loss of Disc Height after Spontaneous Regression of a Herniated Lumbar Disc: A Case Report / 대한척추외과학회지

STUDY DESIGN: Case report. OBJECTIVES: We report 3 cases of loss of disc height after spontaneous regression of a herniated lumbar disc. SUMMARY OF LITERATURE REVIEW: Reports of spontaneous regression of a herniated lumbar disc were identified. MATERIALS AND METHODS: We conservatively treated 3 patients who were diagnosed with a herniated lumbar disc. During outpatient follow-up, radiating pain improved in all patients, but they complained of chronic lower back pain. Magnetic resonance imaging (MRI) was performed for diagnostic purposes. RESULTS: On MRI, spontaneous regression of the herniated lumbar discs was observed, but loss of disc height was also found. CONCLUSIONS: A herniated lumbar disc may be a risk factor for loss of disc height. It is important to recognize that a patient with a herniated lumbar disc can struggle with chronic lower back pain even if spontaneous regression of the herniated lumbar disc occurs.

Trans-Sacral Epiduroscopic Laser Decompression (SELD) for Low back pain secondary to herniated lumbar disc in the Philippines: A case report and review of literature

@#LBP has a lifetime prevalence ranging from 54% to 80%, an annual prevalence of 15-45%, and a point prevalence of 30%. Lumbar radicular pain often results from a Lumbar disc herniation. With recent advances in technique and access in instrumentation, minimally invasive spine surgery has ushered in a renaissance of spine care. SELD has promising positive effects in controlling LBP following HLD. This is a case of a 26 year old with radicular LBP of 2 years duration secondary to HLD, underwent conservative management of LBP but offered no relief and improvement, hence he became the case for the pioneering procedure of SELD in the Philippines. Immediate and significant improvement in the patient was noted. SELD was proven to be an effective therapeutic modality for patients with LBP secondary to HLD.

Efficacy of Epidural Neuroplasty Versus Transforaminal Epidural Steroid Injection for the Radiating Pain Caused by a Herniated Lumbar Disc

OBJECTIVE: To compare the treatment effects of epidural neuroplasty (NP) and transforaminal epidural steroid injection (TFESI) for the radiating pain caused by herniated lumbar disc. METHODS: Thirty-two patients diagnosed with herniated lumbar disc through magnetic resonance imaging or computed tomography were included in this study. Fourteen patients received an epidural NP and eighteen patients had a TFESI. The visual analogue scale (VAS) and functional rating index (FRI) were measured before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment. RESULTS: In the epidural NP group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.00+/-1.52, 4.29+/-1.20, 2.64+/-0.93, 1.43+/-0.51 and those of FRI were 23.57+/-3.84, 16.50+/-3.48, 11.43+/-2.44, 7.00+/-2.15. In the TFESI group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.22+/-2.05, 4.28+/-1.67, 2.56+/-1.04, 1.33+/-0.49 and those of FRI were 22.00+/-6.64, 16.22+/-5.07, 11.56+/-4.18, 8.06+/-1.89. During the follow-up period, the values of VAS and FRI within each group were significantly reduced (p<0.05) after the treatment. But there were no significant differences between the two groups statistically. CONCLUSION: Epidural NP and TFESI are equally effective treatments for the reduction of radiating pain and for improvement of function in patients with a herniated lumbar disc. We recommend that TFESI should be primarily applied to patients who need interventional spine treatment, because it is easier and more cost-effective than epidural NP.

Clinical Outcomes of Percutaneous Plasma Disc Coagulation Therapy for Lumbar Herniated Disc Diseases

OBJECTIVE: This is prospective study of clinical outcomes of percutaneous plasma disc coagulation Therapy (PDCT) in patients with herniated lumbar disc disease (HLD) to evaluate the safety and efficacy in its clinical application and usefulness as a reliable alternative to microscopic discectomy. METHODS: Forty-six patients were enrolled in this study from April 2006 to June 2010. All patients had one-level HLD. Disc degeneration was graded on routine T2-weighted magnetic resonance Image (MRI) using the Pfirrmann's grading system and all index levels were grade 3 and grade 4. Indications for surgery were radiculopathy caused by disc protrusion with soft consistency. MRI was done at one month after the procedure in all patients to check post-PDCT change. The clinical outcomes were evaluated using Visual Analog Scales (VAS) score and MacNab's criteria. RESULTS: This study was approved by the Institutional Review Board of our institution. The age of the study population ranged from 16 to 59 years with a mean age of 37.2 years. There were 29 males and 17 females in this study. The mean period of clinical follow-up was 21 months. The average preoperative VAS score for radiculopathy was 7.4+/-1.4, while the final follow-up VAS score was 1.4+/-0.7 (p<0.001). In MacNab's criteria, 41 patients (89.1%) had achieved favorable improvement (excellent and good) until later follow-up. There were one patient from infection and two patients who needed to convert to open discectomy. CONCLUSION: PDCT is a safe and efficient treatment modality in a selective patient with HLD.

Percutaneous Disc Coagulation Therapy (PDCT) comparing with Automated Percutaneous Lumbar Discectomy (APLD) in Patients of Herniated Lumbar Disc Disease: Preliminary Report

OBJECTIVE: Percutaneous techniques are rapidly replacing traditional open surgery. This is a randomized controlled trial study of clinical outcomes of Percutaneous Plasma Disc Coagulation Therapy (PDCT) in patients with HLD(herniated lumbar disc) as a new percutaneous access in comparison with Automated Percutaneous Lumbar Discectomy (APLD) in its clinical application and usefulness as a reliable alternative method. METHODS: The authors analyzed 25 patients who underwent PDCT randomized 1:1 to 25 who underwent APLD between June, 2010 and October, 2011. All patients had herniated lumbar disc diseases. The clinical outcomes were evaluated using Visual Analog Scales (VAS) score and MacNab's criteria. RESULTS: The age of the patients who underwent PDCT ranged from 29 to 88 years with a mean age of 51.8 years. The age of the APLD undergone patients' population ranged from 30 to 66 with a mean age of 46.0 years. The average preoperative VAS score in PDCT was 7.60 and 1.94 at 7months post-operatively, and in APLD was 7.32, and 3.53 at 7 months post-operatively (p<0.001). In Macnab's criteria, 20 patients (80%) had achieved favorable improvement (excellent and good) in PDCT group. In Macnab's criteria, 16 patients (64%) had achieved favorable improvement in APLD group (p<0.001). CONCLUSION: PDCT can be considered a viable option as a new percutaneous access to herniated lumbar disc. PDCT showed to be more effective than APLD in this study, allowing stable decompression and safe minimally invasive operation to an area desired by the operator in lumbar disc herniation patients, although further long term clinical evaluations are still necessary.

Clinical effect evaluation of minimally invasive surgery in treatmen of herniated lumbar disc / 中国基层医药

Objective To discuss clinical effect of minimally invasive surgery, on herniated lumbar disc.Methods 50 patients of herniated lumbar disc were selected, and 25 patients were treated by micro endoscopy discectomy (MED).Results The treatment effect was better in treatment group, and the surgery time was shorter.1 case in treatment group had erector spinae hematoma, and 9 patients in control group had lumbago, while 2 cases had sciatica behavior.Conclusion The injury of MED was small,the surgery time was shorter,and the recovery was quicker,and it could be popularized in the clinic.

Comparative Study of Lumbar Magnetic Resonance Imaging and Myelography in Young Soldiers with Herniated Lumbar Disc

OBJECTIVE: This study was undertaken to compare the diagnostic performances of magnetic resonance imaging (MRI), MR myelography (MRM) and myelography in young soldiers with a herniated lumbar disc (HLD). METHODS: Sixty-five male soldiers with HLD comprised the study cohort. A visual analogue scale for low back pain (VAS-LBP), VAS for leg radiating pain (VAS-LP), and Oswestry disability index (ODI) were applied. Lumbar MR, MRM, and myelographic findings were checked and evaluated by four independent radiologists, respectively. Each radiologist was asked to score (1 to 5) the degree of disc protrusion and nerve root compression using modified grading systems devised by the North American Spine Society and Pfirrmann and the physical examination rules for conscription in the Republic of Korea. Correlated coefficients between clinical and radiological factors were calculated. Interpretational reproducibility between MRI and myelography by four bases were calculated and compared. RESULTS: Mean patient age was 20.5 +/- 1.1. Mean VAS-LBP and VAS-LP were 6.7 +/- 1.6 and 7.4 +/- 1.7, respectively. Mean ODI was 48.0 +/- 16.2%. Mean MRI, MRM, and myelography scores were 3.3 +/- 0.9, 3.5 +/- 1.0, and 3.9 +/- 1.1, respectively. All scores of diagnostic performances were significantly correlated (p < 0.05). However, none of these scores reflected the severity of patients' symptoms. There was no statistical difference of interpretational reproducibility between MRI and myelography. CONCLUSION: Although MRI and myelography are based on different principles, they produce similar interpretational reproducibility in young soldiers with a HLD. However, these modalities do not reflect the severity of symptoms.

Complication analysis of microendoscopic lumbar disc disectomy / 中国矫形外科杂志

Effect of microendoscopic disectomy (MED) is compared with that of traditional open operation in treating lumbar disc herniation. MED has advantages of less trauma, shorter operating time, quick postoperative recovery, and little suffering, but with more complications. Strictly controlled indication and dedicate operative skill are need to improve the treating effect.

Early Experience with a PDN (Prosthetic Disc Nucleus) Combined with A Coflex Device for treating Two.level Lumbar Degenerative Disease

OBJECTIVE: Discectomy and/or spinal fusion have been the standard treatment options with proven effectiveness to treat degenerative spinal disease. To treat patients with more physiologic effective methods, there have been many efforts to develop various kinds of devices such as posterior dynamic stabilization and disc replacement. We reviewed our early experiences with the combined use of a partial disc replacement device, PDN-Solo(R) (Raymedica, Minneapolis, MN, USA) and an interspinous device, Coflex(R) (Fixanos, Pefonnas, France) in two.level lumbar degenerative disease. METHODS: A total of 13 patients with two.level lumbar degenerative disease underwent an operation from June 2003 to September 2004. A retrospective review of the clinical and radiological data was conducted for all the cases. The intervertebral disc height, the segmental lordotic angle and the total lumbar lordosis were measured. The clinical outcomes were evaluated by using the visual analogue scale (VAS), the Oswestry disability index (ODI) and MacNab's criteria. RESULTS: There were nine men and four women (mean age 34.4 years, range 21-64 years). The mean follow up period was 36.6 months (range 36-43 months). The average segmental lordotic angle of the PDN level was changed from 8.96degrees to 8.41degrees and that of the Coflex level was changed from 5.49degrees to 2.95degrees. The total lumbar lordotic angle was decreased from 33.74degrees to 32.40degrees. The intervertebral disc height of the PDN level was changed from 7.56 mm to 8.41 mm and that of the Coflex level was changed from 9.33 mm to 9.89 mm. The average degree of recovery from back pain was 5.6 points (from 8.9 to 3.3) and the average degree of recovery from leg pain was 4.4 points (from 7.5 to 3.1). The average degree of ODI recovery was 41.7 points (from 67.1 to 25.4). According to MacNab's criteria, the results were excellent in 4 patients (30.8%) and good in 7 patients (53.8%). CONCLUSION: Using the PDN with the Coflex may avoid rigid fixation in specially selected cases with two.level disease, i.e., those patients with spinal stenosis and a herniated lumbar disc. But further biomechanical tests and more longterm follow.up are needed.

Review of Preoperative Conservative Treatment Period and Evidence of Surgeries for Herniated Lumbar Disc

BACKGROUND: The purpose of this study was 1) to review the length of an adequate period of conservative treatment and the appropriate surgical indications for herniated lumbar disc(HLD), 2) to collate the scientific evidences on surgeries for HLD, and 3) to collect expert opinions on HLD. METHODS: We searched for articles in PubMed, the Cochrane Library and KoreaMed up to 1 October 2008, and these articles were concerned with the natural history of HDL, systemic reviews of HDL and expert opinions on HLD. We also searched for meta-analyses and randomized or quasi-randomized controlled trials(RCTs or QRCTs) of surgery for HLD. We performed a meta-analysis using the Cochrane method. The survey consisting of 21 questions was delivered to all the members of the Korean Spinal Neurosurgery Society(KSNS) via E-mail. RESULTS: A total of 59 articles were included in this study. There were 16 articles concerning the period of conservative management and the surgical indications. Among the 33 articles on surgery for HLD, there were 4 meta-analyses, 27 RCTs, and 2 QRCTs. Among the 938 members of the KSNS, 72 responded to the survey. A minimum of 1 to 3 months of conservative management was the most preferred answer(58%), followed by a conservative management period of less than 1 month(33%). Percutaneous endoscopic discectomy was more preferred by the hospitals that specialized in spinetreatment than by the university hospitals(p<0.05). CONCLUSION: Conservative management for a minimum of 2 weeks to 3 months is recommended for patients with tolerable pain only. The patients with neurological compromise or intolerable pain should be considered for surgery. There is strong evidence on the relative effectiveness of surgical discectomy versus chemonucleolysis versus placebo. There is no scientific evidence on the effectiveness of any other form of minimally invasive procedure.

Effects of combining electro-acupuncture, traditional massage, magnet-heating and lumbar traction in the treatment of herniated lumbar disc

Background: Herniated lumbar disc is a very common disease in the age group of 20-50 year olds the worldwide, likewise in Vietnam. There are many traditional therapies for treating this disease, such as electro-acupuncture, traditional massage, and traditional drugs... Objectives: To evaluate the effects and side-effects of combining electro-acupuncture, traditional massage, magnet-heating and lumbar traction in treating herniated lumbar disc. Subjects: 60 patients with herniated lumbar disc, over 20 years of age, were treated at the Department of Traditional Medicine and Rehabilitation, Hospital of Traditional Medicine between July 2006 and October 2007. Method: Prospective, clinical case-controlled trial. Participants were divided equally into two groups: intervention and control group. The treatment lasted for 30 days. Data was analyzed by SPSS software, version 11.5. Results: After 30 days of treatment, there were significant improvements in intervention patients about Lasegue sign, elasticity of lumbar spine, and daily movements when compared to control group. Outcomes after 30 days of treatment in the control group were 16.7% of very good, 43.3% of good, and 40% of moderate. Intervention group had better results, with 46.7% of very good, 46.7% of good, and 6.6% of moderate (p <0.01). There was not any side-effect observed in this trial. Conclusion: The combination of electro-acupuncture, traditional massage, magnet - heating and lumbar traction is a safe method and is an effective treatment for herniated lumbar disc.

Symptomatic Spinal Epidural Gas-Containing Cystic Lesions: Reports of 2 Cases

Symptomatic spinal epidural gas-containing cystic lesion is a rare clinical disease entity. We recently experienced two cases of symptomatic epidural gas-containing cysts that were the main cause of the patients?radiculopathy and the cysts were removed surgically. These lesions were actually gas containing ruptured disc herniations from the vacuum discs at the same level. We report herein on the radiological findings along with conducting a review of the related literature.

The Spontaneous Resorption of Herniated Lumbar Disc: A case report / 대한통증학회지

The most effective treatment methods for a herniated lumbar disc remain questionable. This report follows the patients course, from the onset of pain through the completion of the non-surgical treatment, and shows that a lumbar herniated disc, with radiculopathy, can be successfully treated with a non-surgical approach. This report discusses the possible explanations for disc resorption: retraction into the intervertebral space, dehydration/shrinkage and resorption due to an inflammatory reaction. A non-surgical approach can be an effective treatment option for a herniated lumbar disc.

The Neural Blockades for Low Back Pain and Radicular Pain in Patients

OBJECTIVE: The purpose of this study is to determine the efficacy of neural blockades in patients with herniated lumbar disc and lumbar spinal stenosis. METHODS: The authors reviewed 47 patients with low back and radicular pain, treated with epidural and facet block at the departments of anesthesiology and neurosurgery from June 2000 to November 2001. Epidural blockade was performed via transforaminal, translaminar, or transcaudal route. Facet blocks were performed at the corresponding levels, including above and below the reference level, in patients accompanied with facet syndrome. Improvement was evaluated with pre- and post-block visual analogue scale score and follow-up evaluation was performed at the time of first recurrence to the level of pre-block pain. Time to first recurrence was analyzed with Kaplan-Meyer Survival analysis according to disease entity. RESULTS: After one cycle of blockade, effective responses lasting more than 1 month were 64% more than 3 months were 48% of patients. Median time to first recurrence were 21 weeks in patients with herniated lumbar discs, 7 weeks with lumbar spinal stenosis. The former group showed significant pain improvement(p=0.048). CONCLUSION: Despite of relative short-term effect, neural blockade provides substantial pain relief in majority of patients and this lead early and efficient rehabilitation and exercise therapy.

Phospholipase A2 in Herniated Lumbar Discs: Its Relevance to Pain / 대한척추외과학회지

STUDY DESIGN: A prospective study. OBJECTIVE: To determine whether phospholipase A2(PLA2) activity in herniated lumbar disc is correlated with clinical, radiographic and anatomic signs of the patients with herniated nucleus pulposus. SUMMARY OF LITERATURE REVIEW: Several studies have suggested inflammation around nerve root as a mechanism of sciatica and PLA2 emerges as a key enzyme of the inflammation. However, consensus about association between PLA2 and sciatica has been lacking. In addition, there has been no report that investigated the relationship between cytosolic and membrane PLA2 in herniated disc and patient's symptoms. MATERIALS AND METHODS: Human intervertebral disc materials were obtained from 33 patients who underwent discectomy for HNP. The information was noted about smoking history, medication of NSAID, symptom duration, pain score on a visual analog scale(VAS), positive angle of straight leg raising test (SLR), neurologic deficits, Thompson grade of herniated disc, volume of herniation shown by the MRI and type of herniation based on the operative record. These data were matched to the PLA2 a ctivity in herniated disc measured using Western blotting analysis. PLA2 activity was expressed as the relative percentage compared to that of a 33-year-old female disc obtained during an operation for spinal fracture. The analysis was carried out using Mann-Whitney test, Pearson correlation analysis, simple linear regression analysis. A value of p<0.05 was considered significant. RESULTS: Cytosolic and membrane PLA2 activity showed no statistical relationship to clinical, radiographic and anatomic characteristics of herniated disc. However, membrane PLA2(active form) activity was correlated with the pain score on VAS(p=0.013, r=0.481), while cytosolic PLA2(latent form) showed no statistically significant correlation with the pain score. CONCLUSION: This study demonstrates that membrane PLA2 activity is correlated with the pain score. It also suggests that selective PLA2 inhibitors could be used for the alternative treatment modality of HNP.

Acute Cauda Equina Syndrome Secondary to Lumbar Disc Herniation

OBJECTIVE: Acute cauda equina syndrome secondary to lumbar disc herniation is a rare clinical entity, but its sequelae such as bladder and sexual dysfunction are too severe to overlook. The purpose of this study is to determine the relationship between surgical timing and outcome. METHODS: Between 1994 and 1999, 43 patients(34 male and 9 female), ranging in age from 19 to 67 years(mean: 44.5), were operated due to acute cauda equina syndrome secondary to lumbar disc herniation. All presented with bladder and bowel dysfunction:36(83.7%) had motor weakness and 32(74.4%) had sensory deficit. The levels of herniations were L4/5 in 16 patients, L5/S1 in 10 and L3/4 in 5. RESULTS: The time to surgery from the onset of the symptom ranged from less than 24 hours to more than 14 days:10 patients underwent surgery within 48 hours of onset. The mean follow-up period was 54 months. In motor function recovery, there was no significant difference, but in bladder and sexual functions, there was significant difference according to the duration of symptoms before surgery. CONCLUSION: In acute cauda equina syndrome, emergency decompression surgery should be done. The outcome is good in patients operated within 48 hours compared to those treated more than 48 hours after the onset of the syndrome.

The accuracy of medical history and physical examination to indicate level of nerve root compression in patients with herniated lumbar disc.

A study of 95 cases of surgically documented lumbar disc herniation revealed that the correct level of nerve root compression could be identified in 68.4% by the pattern of radicular pain found in the patients. In 51.6% by physical examination for motor weakness and in 44.2% by an abnormal response of pin prick sensation. The combination of a complete history and physical findings will increase the predictive value of these basic diagnostic tools. This study confirms the usefulness of the medical history and physical examination in the diagnosis of the level of herniated lumbar discs.

Clinical Application of Ozone in Treating the Recurrent Herniated Lumbar Disc after Surgery / 实用放射学杂志

Objective To investigate the therapeutic effect of ozone in treating the recurrent herniated lumbar disc after surgery.Methods Thirty-seven lumbar discs in 37 patinets with recurrent lumbar disc herniation after surgery were injected with ozone under CT-guided.The operative approaches were via lateroposterior position of lumbar vertebrae in 30 and via posterior position in 7 cases.Results The process of injection was done successfully in all patients.Followed-up for three months to one year after the treatment,the cases of clinical therapeutic efficacy of excellent results were 9,the cases of good results were 22,no changes in 6 cases.Conclusion Ozone in treatment of recurrent herniated lumbar disc after surgery is a safe and effective method.

Chronic Spinal Epidural Hematoma after Herniated Lumbar Disc Surgery: A Case Report

We report a case of chronic spinal epidural hematoma in a 21-year old male who was operated on his back due to herniated lumbar disc at the right side of L5-S1 level. The postoperative MRI demonstrated isointense mass on T1W1 and hyperintense on T2W1 at the point where the initial herniated disc compressed the right S1 root. Revision was done and the mass was disclosed to be well-encapsulated chronic spinal epidural hematoma and here-by we report the case with review of literature.