Revalidating Pfirrmann's Magnetic Resonance Image-Based Grading of Lumbar Nerve Root Compromise by Calculating Reliability among Orthopaedic Residents

BACKGROUND: Intervertebral disc herniations lead to subsequent compromise of the nerve root. The root can either have a mere contact with the disc material or be pushed aside or compressed. This was earlier graded by Pfirrmann and colleagues. We intend to revalidate this grading system by performing a reliability analysis among orthopaedic residents. METHODS: Fifty axial cut magnetic resonance (MR) images of the affected lumbar disc level that belonged to different patients (age, 37.8 ± 10.4 years; 33 males and 17 females) were chosen and given to five orthopaedic residents for grading according to the Pfirrmann's MR image-based grading of lumbar nerve root compromise. Responses were received in the form of categorical variables and reliability was assessed. RESULTS: On doing percentage statistics, we found that 14 images had 100% agreement, 22 had 80% agreement and 14 had 60% agreement. We inferred an overall agreement of 80% ± 15.1%. In addition, interrater reliability was determined by calculating the Fleiss' kappa, which was found to be 0.521, signifying moderate agreement. Intrarater reliability was determined by calculating Cohen's kappa, which was found to be 0.696, signifying substantial agreement. CONCLUSIONS: Our residents took only a short time to learn and reproduce this grading system as ratings that proved to be moderately reliable. Even though the value of kappa was slightly lower, reliability was similar to that of the original authors. We think that this grading system can be adopted in day-to-day practice by framing appropriate rules to interpret MR images where the nerve roots are not visible.

The Relationship amongst Intervertebral Disc Vertical Diameter, Lateral Foramen Diameter and Nerve Root Impingement in Lumbar Vertebra

@#Introduction: The vertical diameter of the foramen isdependent upon the vertical diameter of the correspondingintervertebral disc. A decrease in disc vertical diameter hasdirect anatomic consequences to the foraminal diameter andarea available for the nerve root passing through it. Thisstudy is to establish the relationship amongst theintervertebral disc vertical diameter, lateral foramendiameters and nerve root compression in the lumbarvertebra.Materials and Methods: Measurements of the studyparameters were performed using sagittal MRI images. Theparameters studied were: intervertebral disc verticaldiameter (DVD), foraminal vertical diameter (FVD),foraminal transverse diameter (FTD) and nerve root diameter(NRD) of both sides. The relationship between the measuredparameters were then analyzed.Results: A total of 62 MRI images were available for thisstudy. Statistical analysis showed moderate to strongcorrelation between DVD and FVD at all the lumbar levelsexcept at left L23 and L5S1 and right L3L4 and L4L5.Correlation between DVD and FTD were not significant atall lumbar levels. Regression analysis showed that a decreaseof 1mm of DVD was associated with 1.3, 1.7, 3.3, 3.3 and1.3mm reduction of FVD at L1L2, L2L3, L3L4, L4L5 andL5S1 respectively.Conclusion: Reduction of DVD was associated withreduction of FVD. However, FVD was relatively wide forthe nerve root even with complete loss of DVD. FTD wasmuch narrower than the FVD making it more likely to causenerve root compression at the exit foramina. Theseanatomical details should be given consideration in treatingpatients with lateral canal stenosis.

Assessment of Anteroposterior Subpedicular Approach and Oblique Scotty Dog Subpedicular Approach for Selective Nerve Root Block

BACKGROUND: The technique used to administer a selective nerve root block (SNRB) varies depending on individual expertise. Both the anteroposterior (AP) subpedicular approach and oblique Scotty dog subpedicular approach are widely practiced. However, the literature does not provide a clear consensus regarding which approach is more suitable. Hence, we decided to analyse the procedural parameters and clinical outcomes following SNRBs using these two approaches. METHODS: Patients diagnosed with a single lumbar herniated intervertebral disc (HIVD) refractory to conservative management but not willing for immediate surgery were selected for a prospective nonrandomized comparative study. An SNRB was administered as a therapeutic alternative using the AP subpedicular approach in one group (n = 25; mean age, 45 ± 5.4 years) and the oblique Scotty dog subpedicular approach in the other group (n = 22; mean age, 43.8 ± 4.7 years). Results were compared in terms of the duration of the procedure, the number of C-arm exposures, accuracy, pain relief, functional outcome and the duration of relief. RESULTS: Our results suggest that the oblique Scotty dog subpedicular approach took a significantly longer duration (p = 0.02) and a greater number of C-arm exposures (p = 0.001). But, its accuracy of needle placement was 95.5% compared to only 72% using the AP subpedicular approach (p = 0.03). There was no significant difference in terms of clinical outcomes between these approaches. CONCLUSIONS: The AP subpedicular approach was simple and facile, but the oblique Scotty dog subpedicular approach was more accurate. However, a brief window period of pain relief was achieved irrespective of the approaching technique used.

Incomplete Isolated C7 Root Injury Caused by Gunshot Wound: A Case Report / 대한신경손상학회지

Gunshot wounds to the spine cause severe neurological and/or internal organs damages. Although most of publications in the literature are realized on military injuries, increased civilian arming which raises civilian gunshot injuries is a new social danger causing serious health problems. In gunshot injuries to the spine; vertebral column, spinal cord and nerve roots are damaged with direct, indirect and transient cavitation related mechanisms. In this case report, we present 24 years old male patient who had severe pain and monoparesis in left upper extremity followed by gunshot injury to the spine with clinical, radiological and postoperative follow-up findings.

Contralateral Nerve Root Compression after Direct Lateral Lumbar Interbody Fusion / 대한정형외과학회잡지

Direct lateral lumbar interbody fusion (DLIF) has been introduced as an effective new thoracolumbar fusion technique for patients with degenerative lumbar diseases. DLIF associated with easy-to-learn, high fusion rate, improved restoration of spinal alignment, and early patient mobilization due to minimally invasive nature. However, ipsilateral L2–L5 nerve root irritation and injury are well-known complications. However, damage to the contralateral nerve root has been rarely reported and, to the best of our knowledge, there have not been any reports about contralateral nerve root injury after DLIF in Korea. Thus, we report a case of contralateral nerve root compression due to osteophyte from the lower endplate of the vertebral body and position of intervertebral cage after DLIF.

The value of electromyography in localizing lumbosacral radiculopathy / 中华物理医学与康复杂志

Objective To evaluate the accuracy of electromyography (EMG) in localizing the compressed nerve root in lumbar intervertebral disc protrusion (LIDP) pre-operatively.Methods Data were collected on 198 cases of LIDP.Of those,152 cases had positive EMG findings and were treated surgically to relieve compression of the nerve roots caused by LIDP.The intra-operative findings were compared with the pre-operative EMG findings.Results The sensitivity of EMG in detecting radiculopathy was 76.8％ (152/198).Among those 152 EMG positive cases,140 were confirmed in the subsequent operation (92.1％),24 clinically suspected cases of single L5 or S1 compression had indicated of both L5 and S1 damage by EMG and subsequently confirmed on surgical exploration.Conclusions Almost all preoperative EMG findings were confirmed in the subsequent operations (92.1％).Moreover,the indication of combined double nerve root damage by EMG was valuable for guiding the surgical procedure.

Establishment of a rat model of lumbar nerve root compression via modified unilateral hemilaminectomy approach / 中国实验动物学报

Objective To explore the characteristics and advantages of the rat model of lumbar nerve root com -pression established via modified hemilaminectomy approach .Methods Forty Sprague Dawley ( SD) rats were randomly divided into two groups ( experimental group and control group ) for establishing a rat model of lumbar nerve root compres-sion.Modified hemilaminectomy apprpoach was used in the experimental group , while total laminectomy was applied in the control group.Duration of operation, estimated blood loss, wound healing status, postoperative mortality, motor function of the lower extremities , pathological changes and the gray level of cytoplasmic TNF-αand IL-1 expression were observed to e-valuate the characteristics and reliability of the two operation approaches in establishing a rat model of lumbar nerve root compression.Results Compared with the control group , duration of operation , estimated blood loss , wound healing sta-tus, postoperative mortality were significantly better in the experimental group (P<0.01), whereas there was non-signifi-cant difference between two groups with regard to motor function of the lower extremities , pathological changes and gray lev-el of the cytoplasmic expression of TNF-αand IL-1 between the two groups .Moreover, the soft tissue structural alterations were reduced in the experimental group , which might be helpful for the rat postoperative rehabilitation .Conclusions Modified hemilaminectomy approach is a reliable alternative method for establishing a rat model of lumbar nerve root com -pression, which is beneficial to shorten the operative time , improve wound healing status , reduce estimated blood loss and damages of soft tissue , and decrease mortality rate .Moreover , this modified method is more consistent with the principles of animal ethics .

Utility of Limited Protocol Magnetic Resonance Imaging Lumbar Spine for Nerve Root Compression in a Developing Country, Is It Accurate and Cost Effective?

STUDY DESIGN: Cross sectional study. PURPOSE: To determine the accuracy of the screening magnetic resonance study of the lumbar spine in the diagnosis of nerve root compression in cases of low back pain as compared to the routine magnetic resonance imaging (MRI) study of the lumbar spine. OVERVIEW OF LITERATURE: No local study has been conducted for this purpose. In an international study, the reported sensitivity and specificity of screening MRI lumbar spine protocol in the detection of nerve root compression are 54% and 100% respectively. METHODS: Patients of both genders older than 20 years of age with low back pain of any duration or any severity who were referred to the radiology department of Aga Khan University Hospital for MRI of their lumbar spine were evaluated. Two sets of MRI imaging were recruited for each patient: one labeled as 'screening' and the other labeled as 'routine'. The findings of screening MRI were compared with the findings of the routine MRI study. RESULTS: A total of 109 patients fulfilling the inclusion criteria were included in this study. The diagnostic accuracy, specificity and sensitivity of the screening protocol in our study was 100%, 100% and 100%, respectively in comparison with the routine MRI lumbar spine study for the detection of nerve root compression. CONCLUSIONS: Our data proved that the MRI screening study is a highly accurate tool, and its findings are comparable to the routine study for the detection of nerve root compression especially in cases of lumbar spondylosis.

Síndrome de la cola de caballo secundario a hernia discal traumática / Horse-tail syndrome secondary to traumatic disc herniation

La cola de caballo representa la continuación caudal de la médula espinal. Esta porción del sistema nervioso es asiento de numerosas patologías. Se presenta un caso clínico que debutó de forma aguda con un síndrome de la cola de caballo, secundario a una hernia discal lumbar traumática. Se trata de un paciente masculino de 45 años de edad, que acude al servicio de urgencias, porque refiere síntomas que inician siete días antes de forma aguda y progresiva, luego de haber caído de una altura de tres metros. Al interrogarlo existía debilidad muscular del miembro inferior izquierdo y dificultad para caminar. El examen físico corroboró la disminución de la fuerza muscular y arreflexia Aquileo-plantar. Se realizó estudio de resonancia magnética, que demostró una hernia discal extruída en el interespacio L5-S1. El paciente se llevó al salón de urgencia y se realizó exeresis de la hernia. Egresó al séptimo día con discreta mejoría clínica. Se ha seguido en consulta externa durante un periodo de 8 meses, con muy poca recuperación del control esfinteriano, de la actividad motora y sensitiva

Horse-tail represents the caudal continuation of the spinal cord. This portion of the nervous system is the seat of numerous pathologies. We present a case report of acute debuted with a syndrome of the cauda equina, secondary to traumatic lumbar disc herniation. This is a male patient aged 45, who was admitted to the emergency room because he referred acute and progressive symptoms starting seven days before, after falling from three meters high. By questioning, we found muscle weakness in his left leg and difficulty at walking. The physical examination confirmed the decrease in muscle strength and Achilles-plantar areflexia. We performed MRI, which showed extruded disc herniation in L5-S1 interspace. The patient was taken to the emergency room and we performed the hernia excision. He was discharged at the seventh day with mild clinical improvement. We have continued the follow up as outpatient for a period of eight months. There is very little recovery of sphincter control, motor and sensory activity

Occipital Neuralgia after Occipital Cervical Fusion to Treat an Unstable Jefferson Fracture

In this report we describe a patient with an unstable Jefferson fracture who was treated by occipitocervical fusion and later reported sustained postoperative occipital neuralgia. A 70-year-old male was admitted to our center with a Jefferson fracture induced by a car accident. Preoperative lateral X-ray revealed an atlanto-dens interval of 4.8mm and a C1 canal anterior-posterior diameter of 19.94mm. We performed fusion surgery from the occiput to C5 without decompression of C1. The patient reported sustained continuous pain throughout the following year despite strong analgesics. The pain dermatome was located mainly in the great occipital nerve territory and posterior neck. Magnetic resonance images revealed no evidence of cord compression, however a C1 lamina compressed dural sac and C2 root compression could not be excluded. We performed bilateral C2 root decompression via a C1 laminectomy. After decompression, bilateral C2 root redundancy was identified by palpation. After decompression surgery, pain was reduced. This case indicates that occipital neuralgia, suggesting the need for diagnostic block, should be considered in the differential diagnosis of patients with sustained occipital headache after occipitocervical fusion surgery.

Symptomatic Epidural Gas-containing Cyst from Intervertebral Vacuum Phenomenon

Vacuum disc phenomenon is a collection of gas in the intervertebral disc space but rarely causes nerve compression. However, some rare type of vacuum phenomenon in the spinal canal may bring about posterior gas displacement within the epidural space. The authors describe two patients with symptomatic epidural gas-containing cyst that seem to be originating from vacuum phenomenon in the intervertebral disc, causing lumbosacral radiculopathy. Radiographic studies demonstrated intervertebral vacuum phenomenon and accumulation of gas in the lumbar epidural space compressing the dural sac and the nerve root. The nerve root in both patients was compressed by gas containing cyst that was surrounded by thin walled capsule separable from the gaseous degenerated disc space. The speculative mechanism of the nerve root compression is discussed. The possibility of gas containing cyst should be considered in case of the nerve root compression in which epidural gas is present.

La discebtomia simple como tratamiento en el síndrome de compresión radicular lumbar / Simple discectomy in the treatment of lumbar radicular compression syndrome

Para el tratamiento de la compresión radicular lumbar se presentan los resultados obtenidos utilizando la discectomía simple lumbar (Laminotomía bilateral asociadaa discectomía bilateral), en 1214 pacientes que sufrían de dolor lumbar o lumbociática incapacitante. El procedimiento incluye una amplia Laminotomía bilateral, facetectomía parcial y bilateral, superior e inferior, discectomía bilateral osteotomía en V de las apófisis espinosas comprometidas y foraminotomía uni o bilateralcuando estuvieron indicadas. El tiempo de evolución promedio pre-operatorio fue de 3 años y un mes. Todos los pacientes fueron estudiados clínicamente, incluyendo exámenes musculares, neurológicos y de laboratorio. Se analizaron radiografías estáticas y dinámicas de la columna lumbar y en todos se practicó tomografía axial computada desde el segmento L3 al sacro y/o Resonancia Magnética de acuerdo al caso. El control postoperatorio promedio fue de 2 años; 97.1% de los pacientes presentaron un resultado excelente. En el 2.2% de los pacientes no se obtuvieron cambios significativos y no hubo resultados negativos. El 97% de los pacientes con déficit motor volvieron a la normalidad y regresaron a sus actividades habituales en 6 a 8 semanas promedio. No se presentaron complicaciones intraoperatorias, postoperatorias ni de tipo infeccioso. Se concluye que el método es beneficioso y justificable su aplicación en nuestro medio.

Results obtained by using simple discectomy (bilateral laminotomy and discectomy associated) are shown for treatment of lumbar radicular compression syndrome in 1214 patient suffering low-back pain or lumbo-sciatic disableness. The surgical procedure includes ample bilateral laminotomy, partial and bilateral facetectomy, both upper and lower, bilateral discectomy, osteotomy in “V” of the involved spinal processes and uni or bilateral foraminotomy. Preoperative average evolution was 3 years and one month. All patient were clinically studied including physical examination, muscle and neurological examination and laboratory test. Both staticand dynamic roentgenography of the lumbar spine were taken out and Tomography and/or Magnetical Resonancy scan from the L3 segment to the sacrum was performed accord in the every cases. Postoperative average follow up was of 2 years; 97.1% of the patients showed excellent results. 2.2% of the patients did not show any significant changes. There were no negativeresults; 97% of the patients no showing motor and sensitivity deficit, returned to normal activities after 6 to 8 weeks. No infection, intraoperative nor postoperative complications developed. It was concluded that this surgical procedure is benefical, safe and justifiable in this situation.

A Case of Intraspinal Gas-containing Cyst associated with Severe Lumbar Spondylosis

Intraspinal gas collection is rare and also can be a cause of lumbar radiculopathy. Occasionally, the gas formation makes a severe pain which results from nerve root compression. We report a patient who had a radiculopathy caused by the gascontaining cyst in L3-L4 associated with severe spondylosis.

Surgical Treatment of Root Injury after Percutaneous Vertebroplasty: Case Report / 대한척추외과학회지

Percutaneous vertebroplasty using PMMA was first performed in France by Deramond in 1984. It was later used to treat vertebral compression fractures caused by osteoporosis. With osteoporotic compression fractures, reported complication were few and minor. However, the principal risk of such a percutaneous technique is the leak of PMMA into the spinal canal or neural foramina. Despite being uncommon, major neurologic complications demand surgical interventions that prevent permanent neurologic dysfunction. We experienced a case of root compression during percutaneous vertebroplasty, which was treated by early surgical posterior decompression.

Change of the Intervertebral Foraminal Pressure after Removal of the Disc Material

OBJECTIVES: Spinal nerve root compression occurs commonly in conditions, such as herniated nucleus pulposus, spinal stenosis, intervertebral foraminal stenosis, and trauma. However, the pathophysiolosy of the symptoms and signs related to spinal nerve root compression is poorly understood. The purpose of the present study was to assess and compare the changes of various pressures of intervertebral foraminal pressure before and after decompression. METHOD: After laminetomy without foraminotomy was performed, pressure sensor tip of Camino parenchymal type was located at the middle-central portion of the intervertebral foramen and anterior portion of nerve root for the foraminal pressure before decompression of the intervertebral foramen. After laminectomy with foraminotomy, the same method was used for the foraminal pressure after decompression. The authors studied 40 consecutive patients (57 disc spaces) with severe constant root pain to the lower leg, pain unrelived by bed rest, and minimal tension signs, diagnosed by MRI. RESULTS: In patients with intervertebral foraminal stenosis, the intraforaminal pressure was decreased from 86+/-2.23mmHg to 17.1+/-1.51mmHg and in patients without stenosis, from 55.9+/-1.08mmHg to 11.9+/-1.25mmHg. All patients below 20mmHg after decompression showed good outcome, but 4 cases who showed poor outcome had foraminal stenosis, posterolateral type of the herniated disc, and above 30mmHg of foraminal pressure after decompression. CONCLUSION: These findings suggest that if the foraminal pressure falls below 20mmHg after decompression, good outcome can be anticipated. Central type of the herniated disc shows better outcome compared to the posterolateral type.

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.

Lumbar Root Compression Secondary to Epidural Air Retension: A case report / 대한마취과학회지

Air can be introduced into the epidural space during the loss of resistance technique used to identify needle entry into the epidural space. Complications resulting from the injection of air into the epidural space include pneumocephalus, spinal cord and nerve root compression, retroperitoneal air collection, subcutaneous emphysema, venous air embolism, and possibly, incomplete analgesia and anesthesia. We experienced a case of a large epidural collection of air following epidural anesthesia attempted one month before. The CT scan revealed epidural air extending from L1-S1 with moderate compression of nerve root at L4-5.

The Urodynamic Study in Vertebral Disorders with Nerve Root Compression / 대한비뇨기과학회지

PURPOSE: Nerve root compression from spinal stenosis or herniated intervertebral disc(HIVD) may affect bladder function by the disease itself, operation or inappropriate general postoperative care. Preoperative urodynamic study seems to be needed for differential diagnosis of postoperative bladder dysfunction. MATERIALS AND METHODS: Thirty three patients diagnosed as nerve root compression were analysed for urodynamic features prospectively and classified into type I(hyporeflexic, hyposensitive, normal sphincter and hypocontractile, high compliance), type II(hyperreflexic, hypersensitive, normal sphincter and hypocontractile, low compliance), type III(hyperreflexic, hypersensitive, normal sphincter and hypercontractile, low compliance) and normal. Correlation with voiding symptoms, duration of the disease and urodynamic findings was evaluated. RESULTS: The mean age of patients was 56.2 years(29-80 years old), including 21 men and 12 women. Among thirty three patients, 21 had spinal stenosis and twelve patients were diagnosed as HIVD. Urodynamically, there were 16 cases(48.5%) showing type II, 6 cases(18.2%) for type I and 2 cases(6%) for type III. Normal finding was shown in 9 cases(27.3%). No significant difference was shown in mean duration of disease and in urodynamic findings. Patients with voiding symptoms or abnormal urodynamic finding were 20 cases(60.6%) and 24 cases(72.7%), respectively. Among thirteen patients without voiding symptoms, eight patients(61.5%) had abnormal urodynamic findings. CONCLUSIONS: Voiding symptoms and urodynamic findings in patients with nerve root compression were various. Because there is no consistent pattern of dysfunction with any type of nerve root compression disease, preoperative urodynamic study seems to the cornerstone for rational therapy and gives the exact information of bladder function to orthopedic operator.

Fibrous Mass Complicating Epidural Steroid and Local Anesthetic Injection: A Case Report / 대한척추외과학회지

The use of epidural injection of local anesthetics with steroid for the treatment of back pain and sciatica is a widely used procedure. There have been several reports about spinal cord compression by granuloma or fibrous mass related to intrathecal or epidural morphine injection. There have been also some reports about arachnoiditis after epidural injection of steroid. However, there have been no reports regarding dural sac or nerve root compression by fibrous mass after epidural steroid injections. We would report a case of dural sac and nerve root compression secondary to the formation of fibrous mass in the lumbar epidural space after epidural steroid and local anesthetic injections. In this case, the characteristic radiologic findings before and after epidural injection therapy and clinical progress were documented.

Far Lateral Lumbar Disc Herniation at L5-S1 Intervertebral Space: Case Report

One case of far lateral lumbar disc herniation(FLLDH) at left L5-S1 intervertebral space is reported. The herniation of disc material was localized mainly beyond the intervertebral foramen. Metrizamide myelogram was normal and only spine CT scan revealed the protruded disc material compressing the upper root inside and outside of the intervertebral foramen. Accordingly, the presenting symptoms and signs were due to left L5 root compression. Facetectomy was followed by removal of the herniated disc material. The patient was improved well.