Surgical treatment for the far lateral herniated lumbar disc.

Twenty-nine patients underwent surgery for far lateral herniated nucleus pulposus. Average patient age was 65 years in the 14 male and 15 female patients involved. The L4-5 disc was the most commonly herniated level (59%) followed by L3-4 (31%), L5-S1 (7%), and L2-3 (3%). All patients were initially seen with radiculopathy and 23 patients (79%) had motor weakness. A pars interarticularis sparing technique is described for approaching this type of disc herniation. This approach allows direct visualization of the disc and involved root. The results are encouraging with 72% of patients having good or excellent relief of pain. Seventy-one percent of those with preoperative weakness had no weakness or improvement in strength postoperatively. In general, far lateral herniated nucleus pulposus occurs in older patients and at high lumbar disc levels. Postoperative results are similar to the more common posterolateral herniated nucleus pulposus in patients of the same age group. A surgical approach is described to better address the less familiar anatomy.

A systematic approach to disorders of the cervical spine.

Pain in the neck may arise from a clear-cut cause (e.g., an auto accident) or without warning or apparent reason. It may limit exercise, preclude driving, or interfere with sleep, and at its worst make any movement excruciating. Common denominators are rare, although age is often a fundamental factor. It is usually best to begin management conservatively.

Atlantoaxial lateral mass osteoarthritis. A frequently overlooked cause of severe occipitocervical pain.

Localized C1-C2 lateral mass osteoarthritis is a degenerative disorder of the upper cervical spine that has a natural history markedly different from that of degenerative afflictions of the lower cervical spine. Atlantoaxial lateral mass arthritis is a distinct cause of occasionally severe occipitocervical pain in elderly persons. In this series, the diagnosis was suggested by the medical history of nine elderly patients who presented with severe occipitocervical pain (frequently diagnosed as occipital neuralgia). Physical examination demonstrated marked restriction of rotation of the cervical spine to the affected side, and localized tenderness unilaterally at the occipitocervical junction. The diagnosis was confirmed by plain radiographs of the C1-C2 articulation (open-mouth view), demonstrating marked, usually unilateral joint-space narrowing, osteophyte formation, and subchondral sclerosis. Bone scanning demonstrated focal uptake unilaterally at the occipitocervical junction. Additional imaging studies, including computed tomography, magnetic resonance imaging, or cervical myelogram, were performed to rule out coexisting intraspinal pathology. Conservative treatment was usually successful; however, C1-C2 arthrodesis was successful for severe occipitocervical pain due to atlantoaxial lateral mass arthritis not responsive to conservative treatment.

Extraspinal causes of lumbosacral radiculopathy.

Twelve of 12,125 patients who had been referred during a seven-year period to a specialist in spinal disorders were found to have an extraspinal cause of radiculopathy or neuropathy of the lower extremity. The records of these twelve patients were reviewed retrospectively. The average age of the twelve patients was sixty-five years (range, forty-two to seventy-seven years). The cause of the symptoms was an occult malignant tumor in nine patients and a hematoma, an aneurysm of the obturator artery, or a neurilemoma of the sciatic nerve in the others. The average time from the onset of symptoms to the final diagnosis was eight months (range, one month to two years). The most useful test for determination of the correct diagnosis was computed tomography or magnetic resonance imaging of the abdomen and pelvis. Computed tomography or magnetic resonance imaging of the spine and bone-scanning of the whole body were of little help in localizing the disease. In four of the twelve patients, an operation was performed on the basis of an incorrect diagnosis. In dealing with elderly patients who have radiculopathy, one should be suspicious that the cause is outside the spine.

The value of bupivicaine hip injection in the differentiation of coxarthrosis from lower extremity neuropathy.

A series of 18 consecutive patients with roentgenographically proven osteoarthrosis (osteoarthritis, OA) of the hip and spine were evaluated because of concomitant lower extremity pain below the knee. To determine whether the leg symptoms were coxalgic or neuropathic, intraarticular hip bupivicaine was injected as a provocative test. This test allowed correct identification of the source of the pain with a sensitivity of 87%, a specificity of 100%, and an efficiency of 88%. This office test also provides significant savings in terms of diagnostic tests and patient discomfort.

Radiating leg pain in the older patient.

Failure to recognize the presentation frequently leads to misdiagnoses and treatment errors. To avoid such pitfalls, guidelines on seven prominent etiologies are provided. With careful attention to the history and physical examination, an understanding of how those etiologies present will lead to accurate diagnosis and appropriate treatment.

Symptomatic gas-containing disc herniation. Report of four cases.

Intradiscal gas collection, causing the radiographic vacuum phenomenon, is a common finding on radiographic studies of the lumbar spine. Four cases of radiographically documented and surgically confirmed cases of herniated discs containing gas are presented. All four patients presented with radicular symptoms secondary to the gas-containing herniations. Minimal nuclear material was found at surgery; however, all patients experienced relief after the operation.

Diagnosis and management of lumbar disk disease.

Management of the patient with low back pain need not be particularly confusing, expensive, or invasive. A systematic approach to categorizing this ubiquitous symptom etiologically, followed by appropriate choice of diagnostic imaging techniques and an individualized treatment program, will heighten cost-effectiveness and sharply reduce the demand for surgical intervention.

Diskogenic vertebral sclerosis: MR imaging.

Magnetic resonance imaging findings in three patients with diskogenic vertebral sclerosis of the lumbar spine are presented. Increased signal intensity within the vertebral bodies was observed on T2-weighted images that corresponded to areas of bony sclerosis on plain radiography. Decreased signal intensity within the disk space on T2-weighted images serves to differentiate diskogenic sclerosis from infectious spondylitis.

Lower-extremity sensibility testing in patients with herniated lumbar intervertebral discs.

The significance of sensory changes determined by pinprick and light touch in individuals with a herniated lumbar disc has been questioned. Discrepancies may be related to the subjectiveness of the test, failure to use dermatome-specific testing sites, overlap of areas that are innervated by different nerve roots, anatomical variations, or lack of sensitivity of the testing technique. For this study, we assessed the results of sensory examinations of twenty-five patients with documented herniation of a lumbar disc. The examinations were done using Semmes-Weinstein monofilaments, vibrometry, pinprick, and light touch in the autonomous skin areas supplied by the fourth and fifth lumbar and first sacral-nerve roots. Right-left differences in Semmes-Weinstein pressure thresholds of more than fifteen milligrams per square millimeter enabled us to localize disc lesions to a specific root in 100 per cent of patients and differences in vibratory thresholds of more than 3.5 micrometers, to localize the correct level in 88 per cent. Lesser differences in thresholds did not help to identify the involved root. The mean sensory threshold on the side of the disc lesion was found to be significantly greater than that on the opposite side by both vibrometry and pressure aesthesiometry (p less than 0.005). These findings were not duplicated using light touch or pinprick testing. Even with the most sophisticated sensibility-testing techniques, correct identification of the nerve root that was compressed by a herniated lumbar disc was accurate in only 50 per cent of patients.

Intraspinal synovial cyst causing sciatica.

Four patients who had low-back pain and sciatica were diagnosed as having a lumbar intraspinal extradural synovial cyst adjacent to a facet joint between the fourth and fifth lumbar vertebrae. The patients ranged in age from forty-nine to seventy-one years, and the symptoms and signs involved the fourth or fifth lumbar-nerve roots. Roentgenographically, degeneration of the intervertebral discs and facet joints was noted in every patient. Degenerative spondylolisthesis was also a frequent finding. Myelography and computed tomographic scans aided in diagnosis, revealing a soft-tissue lesion, occasionally rimmed with calcification, adjacent to the involved facet joint. The treatment was surgical excision of the cyst, as well as complete laminectomy if there was concomitant spinal stenosis. Follow-up, ranging from eighteen to twenty-five months, revealed complete resolution of the sciatica in all patients.

Low cervical chordoma: report of two cases with documentation by computed tomography and review of the literature.

Chordoma is a slow-growing neoplasm of the axial skeleton. Two cases of lower cervical chordoma are reported, along with a review. Despite combined high voltage radiation therapy and radical surgery chordoma invariably recurs, producing bone erosion and destruction of vital contiguous structures with resulting high morbidity and mortality rates. Computed tomography appears very useful in detecting the early soft tissue involvement and assessing the adequacy of therapy of this spinal malignancy.