A ganglion cyst causing lumbar radiculopathy in a baseball pitcher: a case report.

This report describes a case of a professional baseball pitcher who developed acute left lumbar radicular symptoms after a baseball game and was subsequently sidelined for the rest of the season. Physical examination revealed depressed reflexes in the left posterior tibialis and left medial hamstring muscles, mild weakness in the left extensor hallucis longus, and positive dural tension signs. Magnetic resonance imaging demonstrated an ovoid mass at the L4-L5 level, causing compression of the dura. Surgical resection of the mass resulted in resolution of his symptoms. Pathology revealed that the mass was a ganglion cyst. A ganglion cyst is a rare cause of lumbar radiculopathy and should be considered in the differential diagnosis if a patient with lumbar radiculopathy fails to respond to conservative treatment.

Managing organizational challenge and change: closing an inpatient unit.

The effects of a turbulent health care delivery market have impacted the day-to-day reality of acute care hospitals. One effect is that the supply of acute care hospital beds currently exceeds the demand, a trend that is expected to continue to the year 2000 and beyond. Nursing administrators at St. Marys Hospital Medical Center made the decision to close an inpatient unit in order to better match acute care bed supply to existing demand. Decision support for closure, organizational change, and lessons learned from the closure process are discussed.

Fluoroscopic transforaminal lumbar epidural steroids: an outcome study.

OBJECTIVES: To determine the therapeutic value and long-term effects of fluoroscopic transforaminal epidural steroid injections in patients with refractory radicular leg pain. BACKGROUND DATA: Although numerous studies have evaluated the efficacy of traditional transsacral (caudal) or translaminar (lumbar) administration of epidural steroids, to our knowledge no studies have assessed specifically the therapeutic value of fluoroscopic transforaminal epidural steroids. STUDY DESIGN: A prospective case series that investigated the outcome of patients with lumbar herniated nucleus pulposus and radiculopathy who received fluoroscopic transforaminal epidural steroid injections. METHODS: Patients who met our inclusion criteria received fluoroscopically guided, contrast-enhanced transforaminal epidural administration of anesthetic and steroid directly at the level and side of their documented pathology. Patients were evaluated by an independent observer and received sequential questionnaires before and after injection, documenting pain level, activity level, and patient satisfaction. RESULTS: Sixty-nine patients met our inclusion criteria and were followed for an average period of 80 weeks (range, 28 to 144 weeks); 75.4% of patients had a successful long-term outcome, reporting at least a >50% reduction between preinjection and postinjection pain scores, as well as an ability to return to or near their previous levels of functioning after only 1.8 injections per patient (range, 1 to 4 injections). Of our patients, 78.3% were satisfied with their final outcomes. CONCLUSIONS: Fluoroscopic transforminal epidural steroids are an effective nonsurgical treatment option for patients with lumbar herniated nucleus pulposus and radiculopathy in whom more conservative treatments are not effective and should be considered before surgical intervention.

Vertebral osteomyelitis due to Roseomonas species: case report and review of the evaluation of vertebral osteomyelitis.

We report what we believe is the first case of vertebral osteomyelitis caused by Roseomonas species. The diagnosis of vertebral osteomyelitis can be difficult. The case illustrates the importance of the establishment of an etiologic diagnosis in vertebral osteomyelitis. The features of Roseomonas species and the evaluation of cases of vertebral osteomyelitis are reviewed.

Cervical spine nerve root compression. An analysis of neuroforaminal pressures with varying head and arm positions.

STUDY DESIGN: Pressure measurements were taken in the neural foramina of C5, C6, and C7 nerve roots at various positions of the head and ipsilateral arm in eight fresh cadavers. OBJECTIVES: The purpose of the study was to correlate clinical signs and symptoms with pressures generated in the neural foramen of patients with cervical radiculopathy. SUMMARY OF BACKGROUND DATA: The reliability of the clinical signs used to diagnose cervical disc herniations has remained controversial. Previous studies have shown the active relationship of the cord and nerve roots to the various movements of the spine. METHODS: A standard anterior approach was made to the cervical spine and the C5-C7 roots identified. A balloon catheter, attached to a pressure transducer and monitor, was inserted in the neural foramen. The head was then taken through varying degrees of flexion and extension in combination with the arm neutral or abducted. RESULTS: Increasing neck extension led to significant pressure changes at each root tested. With the movement of the arm from the neutral to abducted position, the pressure was significantly relieved. The results with neck flexion were variable. CONCLUSIONS: The significance of this study is that it offers an explanation for the clinical observation of increasing radicular symptoms with neck extension and relief of these symptoms with the shoulder abduction relief maneuver in the setting of a cervical radiculopathy.

The cluster phenomenon in patients who have multiple vertebral compression fractures.

Little is known about the natural history of patients who have multiple compression fractures. During an eight-year period, eight patients who suffered relentless nonmechanical back pain after an initial compression fracture were evaluated. Radiographs and radionuclide bone scans were obtained in all eight patients and showed the temporal clustering of at least five spontaneous thoracic or lumbar vertebral compression fractures within a period of eight months. The patient database during this eight-year period included 21 patients with a similar number of fractures but without the phenomenon of temporal clustering. Age and gender distribution, premorbid activity levels, presence of secondary causes of osteopenia, dietary history, and vertebral bone density measurements were similar in both groups. Five of the eight patients with cluster fractures were on chronic glucocorticoid therapy for treatment of an underlying illness. All five patients experienced an exacerbation of their chronic illness that required an increase in the dose of their steroid medication within three months preceding the onset of the cluster fractures. No patient in the noncluster fracture control group experienced a similar exacerbation of an underlying illness or required a similar boost in their steroid medication. The temporal clustering of numerous fractures (cluster phenomenon) is a cause of transient severe disability in patients who have profound osteopenia, and may be precipitated by exacerbation of an intercurrent illness or by an associated obligate increase in glucocorticoid medication in a patient with preexisting severe osteopenia.

Infectious disease of the spine. Diagnostic and treatment considerations.

Excellence in treating spinal infections demands recognition of the fact that all spine infections are potential disasters. One needs to possess a complete knowledge of the pathology and pathogenesis of these disorders. An aggressive diagnostic approach is required. Surgery may be required for diagnosis, abscess drainage, neurologic involvement, deformity, or refractoriness to conservative therapy. Selection of the proper operation, as well as its skillful execution, are prerequisites. These goals, along with the appropriate use of antibiotics, and, most importantly, vigilance for the presence of spinal infection, will allow us to avoid the high rates of morbidity and mortality experienced by others in the past.

Neurapraxia of the cervical spinal cord with transient quadriplegia.

The purpose of this study was to define as a distinct clinical entity the syndrome of neurapraxia of the cervical spinal cord with transient quadriplegia. The sensory changes include burning pain, numbness, tingling, and loss of sensation, while the motor changes range from weakness to complete paralysis. The episodes are transient and complete recovery usually occurs in ten to fifteen minutes, although in some patients gradual resolution occurs over a period of thirty-six to forty-eight hours. Except for burning paresthesia, pain in the neck is not present at the time of injury and there is complete return of motor function and full, pain-free motion of the cervical spine. In our series, routine roentgenograms of the cervical spine were negative for fractures or dislocations in all patients. However, the roentgenographic findings did include developmental spinal stenosis in seventeen patients, congenital fusion in five patients, cervical instability in four patients, and intervertebral disc disease in six patients. Spinal stenosis was determined by two different roentgenographic methods. The first was the standard method, and the second was a ratio method devised by us. Both measurements were made at the level of the third through the sixth vertebral body on a routine lateral roentgenogram of the cervical spine that was available for twenty-four of the thirty-two patients and for a control group of forty-nine male subjects of similar age who did not have any neurological complaints. Using the ratio method, a measurement of less than 0.80 indicated significant spinal stenosis in the group of twenty-four patients for whom roentgenograms were available, as compared with a ratio of approximately 1.00 or more in the control group. There was statistically significant spinal stenosis (p less than 0.0001) in all of the patients as compared with the control subjects by both methods of determining spinal stenosis. A survey of 503 schools participating in National Collegiate Athletic Association (NCAA) football in the 1984 season found that 1.3 per 10,000 athletes had a history that was suggestive of neurapraxia of the cervical spinal cord. The phenomenon of neurapraxia of the cervical spinal cord occurs in individuals with developmental stenosis of the cervical spine, congenital fusion, cervical instability, or protrusion of an intervertebral disc in association with a decrease in the anteroposterior diameter of the spinal canal. We postulate that in athletes with diminution of the anteroposterior diameter of the spinal canal the spinal cord can, on forced hyperextension or hyperflexion, be compressed, causing transitory motor and sensory manifestations.(ABSTRACT TRUNCATED AT 400 WORDS)

The Pennsylvania Plan II: an algorithm for the management of lumbar degenerative disc disease.

We have thus presented a series of decision-making processes that are easy to follow, clearly defined, and cost effective. We have found that with the use of this decision-making algorithm our patients receive the therapeutic measures most helpful at the optimal time and are neither denied helpful surgery nor submitted to operations that are useless surgical exercises. With the use of this protocol, we believe that our efficiency as surgeons, physicians, and advisors will increase and the specter of fear found in the general population regarding low back pain will diminish.