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Cuendet D, Valsecchi D, Najberg H, Maestretti G, Medlin F. Neuromuscular ultrasound changes in unilateral symptomatic subacute lumbosacral radiculopathy: A prospective simple blinded cohort study. Muscle Nerve 2024; 69:566-571. [PMID: 38390643 DOI: 10.1002/mus.28061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 01/21/2024] [Accepted: 01/26/2024] [Indexed: 02/24/2024]
Abstract
INTRODUCTION/AIMS Lumbosacral radiculopathy (LR) is a common disorder. Neuromuscular ultrasound (NMU) is a rapidly evolving technique for the investigation of peripheral nerve and muscle disorders, but studies using NMU in LR are lacking. The aim of the present study was to investigate ultrasonographic neuromuscular changes distant from root compression in patients with subacute to chronic compressive LR with motor impairment. METHODS Patients with unilateral subacute to chronic L4, L5, or S1 radiculopathy with motor impairment and confirmed by magnetic resonance imaging were included. The sciatic and femoral nerve cross-sectional areas (CSA), the CSA of lower limb muscles, and muscle fasciculation detection rate were assessed using a pre-specified neuromuscular ultrasound evaluation with blinded side-to-side comparison. RESULTS Of the 18 included patients, 66% were male and the mean age was 51 years. Overall, 16.7% had L4, 55.5% L5, and 27.8% S1 radiculopathy, mostly due to disc herniation (83%). Sciatic nerve CSA of the symptomatic side was increased (61.4 mm2 vs. 51.3 mm2; p = .001), and the fasciculation detection rate was higher in the affected muscles (delta = 13%, p = .007) compared to unaffected ones. Muscle CSA in affected and nonaffected muscles was decreased on the symptomatic side. DISCUSSION NMU evaluation in patients with symptomatic subacute to chronic LR revealed sciatic nerve enlargement distant from nerve root compression and higher fasciculation rates. These structural findings on NMU might be due to an axonal repair mechanism and an inflammatory response with endoneurial edema induced by ongoing nerve damage and potentially reflect progressive axonal loss.
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Affiliation(s)
- David Cuendet
- Neurology Unit, Department of Internal Medicine, Cantonal Hospital Fribourg, Fribourg, Switzerland
- Faculty of Science and Medicine, University Fribourg, Fribourg, Switzerland
| | - Daniele Valsecchi
- Faculty of Science and Medicine, University Fribourg, Fribourg, Switzerland
- Neuro-spinal Unit, Department of Orthopedics surgery and Traumatology, Cantonal Hospital Fribourg, Fribourg, Switzerland
| | - Hugo Najberg
- Faculty of Science and Medicine, University Fribourg, Fribourg, Switzerland
| | - Gianluca Maestretti
- Faculty of Science and Medicine, University Fribourg, Fribourg, Switzerland
- Neuro-spinal Unit, Department of Orthopedics surgery and Traumatology, Cantonal Hospital Fribourg, Fribourg, Switzerland
| | - Friedrich Medlin
- Neurology Unit, Department of Internal Medicine, Cantonal Hospital Fribourg, Fribourg, Switzerland
- Faculty of Science and Medicine, University Fribourg, Fribourg, Switzerland
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Mansfield M, Thacker M. Integrating jigsaw puzzle thinking into practice: the assessment of cervical spine radiculopathy. Curr Opin Support Palliat Care 2023; 17:135-141. [PMID: 37389587 DOI: 10.1097/spc.0000000000000656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
PURPOSE OF REVIEW Cervical spine radiculopathy (CSR) presents a complex socioeconomic problem for patients, clinicians, families, employers and healthcare systems. Due to the heterogeneity of clinical presentation and underlying mechanisms, clinical assessment can be challenging. This review will examine the literature on the underlying pathophysiology and studies investigating the holistic assessment strategies for this disabling condition. The authors will focus particular attention on the psychological factors associated with CSR and the physical and imaging strategies to establish a diagnosis. RECENT FINDINGS Contemporary CSR assessment should identify the underlying pathomechanisms and how this may impact the somatosensory nervous system integrity and function. No physical assessment test in isolation will establish CSR diagnosis; therefore, clinicians should utilise a cluster of tests and recognise the potential limitations as part of a clinical reasoning framework. The assessment of the somatosensory nervous system can provide insights into particular subgroups of CSR presentation, which may provide interesting opportunities to continue to enhance individualised assessment and management strategies for CSR. The interplay between psychological factors can influence the diagnosis and recovery times for a person with CSR, and clinicians should continue to explore how these factors may influence a person's prognosis. The authors will discuss the opportunities for future research and limitations of contemporary approaches to assessment, underpinned by evidence, and how this supports a clinical assessment to establish CSR diagnosis. SUMMARY Research should continue to investigate how clinicians assess the interplay between physical and psychological factors to inform the establishment of CSR. Specifically, there is a need to investigate the validity and reliability of combining somatosensory, motor and imaging assessment findings to reach a diagnosis and inform onward management plans.
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Affiliation(s)
- Michael Mansfield
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich
- School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Edgbaston
- Centre of Precision Rehabilitation for Spinal Pain, University of Birmingham, Birmingham, UK
| | - Mick Thacker
- School of Physiotherapy, Royal College of Surgeons Ireland, Dublin 2, Ireland
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Fourré A, Monnier F, Ris L, Telliez F, Michielsen J, Roussel N, Hage R. Low-back related leg pain: is the nerve guilty? How to differentiate the underlying pain mechanism. J Man Manip Ther 2023; 31:57-63. [PMID: 35735104 PMCID: PMC10013353 DOI: 10.1080/10669817.2022.2092266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Low back pain (LBP) that radiates to the leg is not always related to a lesion or a disease of the nervous system (neuropathic pain): it might be nociceptive (referred) pain. Unfortunately, patients with low-back related leg pain are often given a variety of diagnoses (e.g. 'sciatica'; 'radicular pain'; pseudoradicular pain"). This terminology causes confusion and challenges clinical reasoning. It is essential for clinicians to understand and recognize predominant pain mechanisms. This paper describes pain mechanisms related to low back-related leg pain and helps differentiate these mechanisms in practice using clinical based scenarios. We illustrate this by using two clinical scenarios including patients with the same symptoms in terms of pain localization (i.e. low-back related leg pain) but with different underlying pain mechanisms (i.e. nociceptive versus neuropathic pain).
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Affiliation(s)
- Antoine Fourré
- Department of Neurosciences, Research Institute for Health Sciences and Technology, University of Mons, Mons, Belgium.,Faculty of Medicine and Health Sciences, Rehabilitation Sciences and Physiotherapy (MOVANT), University of Antwerp, Antwerp, Belgium.,Traitement Formation Thérapie Manuelle (TFTM), Physiotherapy Center, Brussels, Belgium
| | - Félix Monnier
- Department of Neurosciences, Research Institute for Health Sciences and Technology, University of Mons, Mons, Belgium
| | - Laurence Ris
- Department of Neurosciences, Research Institute for Health Sciences and Technology, University of Mons, Mons, Belgium
| | - Frédéric Telliez
- Institut d'Ingénierie de la Santé-UFR de Médecine, Centre Universitaire de Recherche en Santé-Laboratoire Péritox, Université de Picardie Jules Verne, Amiens, France
| | - Jef Michielsen
- Faculty of Medicine and Health Sciences, Rehabilitation Sciences and Physiotherapy (MOVANT), University of Antwerp, Antwerp, Belgium.,Orthopedic Department, University Hospital, Antwerp, Belgium
| | - Nathalie Roussel
- Faculty of Medicine and Health Sciences, Rehabilitation Sciences and Physiotherapy (MOVANT), University of Antwerp, Antwerp, Belgium
| | - Renaud Hage
- Traitement Formation Thérapie Manuelle (TFTM), Physiotherapy Center, Brussels, Belgium.,Centre de Recherche et de Formation (CeREF), HELHa, Mons, Belgium
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Poorer surgical outcomes at 2 years postoperatively in patients with lumbar spinal stenosis with long-term preoperative leg numbness: a single-center retrospective study. J Orthop Surg Res 2022; 17:547. [PMID: 36528773 PMCID: PMC9759894 DOI: 10.1186/s13018-022-03452-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The purpose of this study was to assess whether differences in duration of preoperative leg numbness lead to different surgical outcomes. METHODS This study included patients with lumbar spinal stenosis (LSS) who underwent lumbar fusion surgery in our hospital from January 2018 to September 2020. Patients were divided into three groups based on duration of preoperative leg numbness: no numbness (NN) group, short-term numbness (STN) group (leg numbness ≤ 3 months) and long-term numbness (LTN) group (leg numbness > 3 months). The Numerical Rating Scale of leg pain (NRS-LP) and leg numbness (NRS-LN), Oswestry Disability Index (ODI) and Short-Form Health Survey (SF-36) were collected before surgery and at 3, 6, 12 and 24 months postoperatively. RESULTS 178 patients were included in this study. At 24 months postoperatively, NRS-LP was significantly higher in LTN than in NN [NN vs. STN vs. LTN: 0 (0,1) vs. 0 (0,1) vs. 1 (0,1)] (p = 0.033). NRS-LN in STN [2 (1,3)] was significantly lower than in LTN [3 (2,3)] (p < 0.001). SF-36 was significantly lower in LTN than in other two groups (NN vs. STN vs. LTN: 86.10 ± 6.02 vs. 84.09 ± 5.59 vs. 78.93 ± 6.57) (p < 0.001). ODI was significantly higher in LTN than in other two groups [NN vs. STN vs. LTN: 18 (15,22) vs. 18 (16,20) vs. 21 (19,24)] (p = 0.001). CONCLUSIONS Patients with LSS with long-term preoperative leg numbness have poorer outcomes at 2 years postoperatively. Surgical intervention should be performed before persistent leg numbness for more than 3 months to obtain a better prognosis.
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Zou T, Chen H, Wang PC, Sun HH, Feng XM. Predictive factors for residual leg numbness after decompression surgery for lumbar degenerative diseases. BMC Musculoskelet Disord 2022; 23:910. [PMID: 36224568 PMCID: PMC9559037 DOI: 10.1186/s12891-022-05848-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 09/19/2022] [Indexed: 11/10/2022] Open
Abstract
Background The purpose of this study is to evaluate the change patterns of leg numbness (LN) after lumbar decompression surgery (LDS), and to find the predictive factors that affect the recovery of numbness. Methods Patients who underwent LDS in our institution between August 2020 and July 2021 were prospectively enrolled in this study, and were followed by a 12-month follow-up. The degree of LN, leg pain (LP) and the disability were assessed using the visual analog scale (VAS) and oswestry disability index (ODI). Results A total of 314 patients finished the 12-month follow-up. The preoperative mean VAS-LN score was 3.49 ± 2.44, which decreased to 1.91 ± 1.30 at 3 months, to 1.29 ± 0.97 at 6 months and to 1.26 ± 0.96 at 12 months after surgery. The preoperative mean VAS-LP score was 6.05 ± 1.30, which decreased to 2.00 ± 0.86 at 3 months, to 1.02 ± 0.80 at 6 months, and to 0.49 ± 0.71 at 12 months after surgery. The preoperative mean ODI score was 27.90 ± 7.08, which decreased to 9.73 ± 3.09 at 3 months, to 6.72 ± 2.98 at 6 months, and to 4.57 ± 2.76 at 12 months after surgery. Via multivariate logistic regression analysis, only preoperative VAS-LN score (p < 0.001*) was identified as a significantly independent predictive factor for residual LN after operation. Conclusion Clinically significant improvement in LN was observed in the majority of patients within 6 months after LDS, and the improvement of VAS-LN was slower than the VAS-LP. High pre-operative VAS-LN score can independently predict the presence of residual LN after surgery at 12-month follow up.
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Affiliation(s)
- Tao Zou
- Department of Orthopedics, Clinical Medical College of Yangzhou University, No.98 Nantong West Road, 225001, Yangzhou, Jiangsu province, China
| | - Hao Chen
- Department of Orthopedics, Clinical Medical College of Yangzhou University, No.98 Nantong West Road, 225001, Yangzhou, Jiangsu province, China
| | - Ping-Chuan Wang
- Department of Orthopedics, Clinical Medical College of Yangzhou University, No.98 Nantong West Road, 225001, Yangzhou, Jiangsu province, China
| | - Hui-Hui Sun
- Department of Orthopedics, Clinical Medical College of Yangzhou University, No.98 Nantong West Road, 225001, Yangzhou, Jiangsu province, China.
| | - Xin-Min Feng
- Department of Orthopedics, Clinical Medical College of Yangzhou University, No.98 Nantong West Road, 225001, Yangzhou, Jiangsu province, China.
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Minetama M, Kawakami M, Teraguchi M, Matsuo S, Enyo Y, Nakagawa M, Yamamoto Y, Nakatani T, Sakon N, Nagata W, Nakagawa Y. MRI grading of spinal stenosis is not associated with the severity of low back pain in patients with lumbar spinal stenosis. BMC Musculoskelet Disord 2022; 23:857. [PMID: 36096768 PMCID: PMC9465904 DOI: 10.1186/s12891-022-05810-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background Although lumbar spinal stenosis (LSS) often coexists with other degenerative conditions, few studies have fully assessed possible contributing factors for low back pain (LBP) in patients with LSS. The purpose of this study was to identify factors associated with the severity of LBP in patients with LSS. Methods The patients with neurogenic claudication caused by LSS, which was confirmed by magnetic resonance imaging (MRI) were included in this cross-sectional study. Data included ratings of LBP, buttock and leg pain, and numbness on a numerical rating scale (NRS), 36-item Short-Form Survey (SF-36) scores, muscle mass measured by bioelectrical impedance analysis, and radiographic measurements including lumbopelvic alignment and slippage. The severity of LSS, endplate defects, Modic endplate changes, intervertebral disc degeneration, and facet joint osteoarthritis were evaluated on MRI. Spearman correlation and multivariate linear regression analyses were used to examine the factors associated with the severity of LBP (NRS score). Results A total of 293 patients (135 male and 158 female, average age 72.6 years) were analyzed. LBP was moderately correlated with buttock and leg pain, and buttock and leg numbness. Significant but weak correlations were observed between LBP and body mass index, appendicular and trunk muscle mass, all domains of SF-36, pelvic tilt, total number of endplate defects and Modic endplate changes, and summary score of disc degeneration grading, but not severity or number of spinal stenoses. In the multivariate regression analysis, age, female sex, trunk muscle mass, diabetes, NRS buttock and leg pain, NRS buttock and leg numbness, SF-36 vitality, pelvic tilt, and total number of endplate defects were associated with the severity of LBP. Conclusions Trunk muscle mass, lumbopelvic alignment, and endplate defects, but not severity of stenosis are partly associated with severity of LBP, but buttock and leg pain and buttock and leg numbness have strongest relationships with LBP in patients with LSS.
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Affiliation(s)
- Masakazu Minetama
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan.
| | - Mamoru Kawakami
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan.,Department of Orthopaedic Surgery, Saiseikai Wakayama Hospital, 45 Jyunibancho, Wakayama, 640-8158, Japan
| | - Masatoshi Teraguchi
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Sachika Matsuo
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Yoshio Enyo
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Masafumi Nakagawa
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Yoshio Yamamoto
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Tomohiro Nakatani
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Nana Sakon
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Wakana Nagata
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
| | - Yukihiro Nakagawa
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama, 649-7113, Japan
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Song SY, Nam DC, Moon DK, Lee DY, Lee EC, Kim DH. Surgical decompression timing for patients with foot drop from lumbar degenerative diseases: a meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 31:551-560. [PMID: 34718868 DOI: 10.1007/s00586-021-07045-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/12/2021] [Accepted: 10/20/2021] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To compare the outcomes of early (within 1 month after foot drop) decompression versus late (1 month or more after foot drop) decompression in order to determine the optimal surgical intervention timing for lumbar degenerative diseases. METHODS The MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science and SCOPUS electronic databases were searched for relevant articles published until May 2021 were conducted. Cochrane Collaboration guidelines were used for data extraction and quality assessment. Outcomes of interest were manual muscle testing (MMT) and recovery rate (MMT ≥ 4) for foot drop in lumbar degenerative diseases. RESULTS Six clinical studies were retrieved, including 312 randomized participants. One hundred fifty-seven patients underwent early decompression surgery, and 155 underwent late decompression surgery. There were significant differences between the two groups in recovery rate (95% confidence interval [CI] 1.59, 2.57) and neurological improvement (95% confidence interval [CI] 0.21, 1.66). Early surgical decompression provided better recovery rate and neurological improvement for foot drop in lumbar degenerative diseases than late surgical decompression. CONCLUSION Early surgical decompression within was beneficial in terms of recovery rate and neurological improvement compared with late surgery. Early surgical decompression (within 1 month) is recommended for patients with foot drop in lumbar degenerative diseases.
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Affiliation(s)
- Sang-Youn Song
- Department of Orthopaedic Surgery, Institute of Health Science, Gyeongsang National University School of Medicine and Hospital, 15, Jinju-daero 816 beon-gil, Jinju, Gyeongsangnam-do, 660-751, Republic of Korea
| | - Dae Cheol Nam
- Department of Orthopaedic Surgery, Institute of Health Science, Gyeongsang National University School of Medicine and Hospital, 15, Jinju-daero 816 beon-gil, Jinju, Gyeongsangnam-do, 660-751, Republic of Korea
| | - Dong-Kyu Moon
- Department of Orthopaedic Surgery, Institute of Health Science, Gyeongsang National University School of Medicine and Hospital, 15, Jinju-daero 816 beon-gil, Jinju, Gyeongsangnam-do, 660-751, Republic of Korea
| | - Dong-Yeong Lee
- Department of Orthopaedic Surgery and Joint Center, Barun Hospital, Jinju, Republic of Korea
| | - Eun-Chang Lee
- Department of Orthopaedic Surgery, Institute of Health Science, Gyeongsang National University School of Medicine and Hospital, 15, Jinju-daero 816 beon-gil, Jinju, Gyeongsangnam-do, 660-751, Republic of Korea
| | - Dong-Hee Kim
- Department of Orthopaedic Surgery, Institute of Health Science, Gyeongsang National University School of Medicine and Hospital, 15, Jinju-daero 816 beon-gil, Jinju, Gyeongsangnam-do, 660-751, Republic of Korea.
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Chan AK, Ballatori A, Nyayapati P, Mummaneni NV, Coughlin D, Liebenberg E, Külling FA, Zhang N, Waldorff EI, Ryaby JT, Lotz JC. Pulsed Electromagnetic Fields Accelerate Sensorimotor Recovery Following Experimental Disc Herniation. Spine (Phila Pa 1976) 2021; 46:E222-E233. [PMID: 33475275 DOI: 10.1097/brs.0000000000003762] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN An experimental animal study. OBJECTIVE The aim of this study was to investigate the effect of pulsed electromagnetic fields (PEMF) on recovery of sensorimotor function in a rodent model of disc herniation (DH). SUMMARY OF BACKGROUND DATA Radiculopathy associated with DH is mediated by proinflammatory cytokines. Although we have demonstrated the anti-inflammatory effects of PEMF on various tissues, we have not investigated the potential therapeutic effect of PEMF on radiculopathy resulting from DH. METHODS Nineteen rats were divided into three groups: positive control (PC; left L4 nerve ligation) (n = 6), DH alone (DH; exposure of left L4 dorsal root ganglion [DRG] to harvested nucleus pulposus and DRG displacement) (n = 6), and DH + PEMF (n = 7). Rodents from the DH + PEMF group were exposed to PEMF immediately postoperatively and for 3 hours/day until the end of the study. Sensory function was assessed via paw withdrawal thresholds to non-noxious stimuli preoperatively and 1 and 3 days postoperatively, and every 7 days thereafter until 7 weeks after surgery. Motor function was assessed via DigiGait treadmill analysis preoperatively and weekly starting 7 days following surgery until 7 weeks following surgery. RESULTS All groups demonstrated marked increases in the left hindlimb response threshold postoperatively. However, 1 week following surgery, there was a significant effect of condition on left hindlimb withdrawal thresholds (one-way analysis of variance: F = 3.82, df = 2, P = 0.044) where a more rapid recovery to baseline threshold was evident for DH + PEMF compared to PC and DH alone. All groups demonstrated gait disturbance postoperatively. However, DH + PEMF rodents were able to regain baseline gait speeds before DH and PC rodents. When comparing gait parameters, DH + PEMF showed consistently less impairment postoperatively suggesting that PEMF treatment was associated with less severe gait disturbance. CONCLUSION These data demonstrate that PEMF accelerates sensorimotor recovery in a rodent model of DH, suggesting that PEMF may be reasonable to evaluate for the clinical management of patients with herniation-associated radiculopathy.Level of Evidence: N/A.
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Affiliation(s)
- Andrew K Chan
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA
- Department of Orthopaedic Surgery University of California, San Francisco, San Francisco, CA
| | - Alexander Ballatori
- Department of Orthopaedic Surgery University of California, San Francisco, San Francisco, CA
| | - Priya Nyayapati
- Department of Orthopaedic Surgery University of California, San Francisco, San Francisco, CA
| | - Nikhil V Mummaneni
- Department of Orthopaedic Surgery University of California, San Francisco, San Francisco, CA
| | - Dezba Coughlin
- Department of Orthopaedic Surgery University of California, San Francisco, San Francisco, CA
| | - Ellen Liebenberg
- Department of Orthopaedic Surgery University of California, San Francisco, San Francisco, CA
| | - Fabrice A Külling
- Department of Orthopaedics and Traumatology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | | | | | | | - Jeffrey C Lotz
- Department of Orthopaedic Surgery University of California, San Francisco, San Francisco, CA
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Vaitkus A, Šipylaitė J. Qualitative Sensory Testing in Outcome Prediction of Transforaminal Epidural Steroid Injection for Chronic Painful Unilateral Lumbosacral Radiculopathy: Prospective Observational Study. Pain Pract 2021; 21:618-629. [PMID: 33502060 DOI: 10.1111/papr.12997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 01/11/2021] [Accepted: 01/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Transforaminal epidural steroid injection (TFESI) is widely practiced for the treatment of radicular pain. As its effectiveness is still subject to debate, a better patient selection for TFESI is necessary. We aimed to evaluate the potential of bedside-suitable qualitative sensory testing (QualST) to determine the early effectiveness of TFESI for the treatment of chronic lumbosacral radiculopathy (LSR)-related pain. METHODS Thirty-six patients with chronic painful unilateral LSR were evaluated in a prospective observational study using five standardized sensory tests (10 g monofilament, 200 to 400 mN brush, Lindblom rollers with controlled 25 and 40°C temperature, and 40 g neurological pin). Quality of sensory perceptions on the painful leg was compared to the non-painful leg and rated as normal sensitivity, hyposensitivity, or hypersensitivity. Pain and related characteristics were evaluated before TFESI, 1 week after and 4 weeks after intervention. RESULTS Seven sensory phenotypes were distinguished according to individual sets of sensory disturbances acquired with five sensory tests. Patients were grouped into four groups of allied phenotypes (normal sensitivity, hyposensitivity to 1 to 3 modalities, hyposensitivity to 4 to 5 modalities, and hypersensitivity). The whole study group showed significant improvement in most parameters of outcome measurements. Statistical analysis revealed some significant differences between sensory groups in patient-reported treatment effect scales after 4 weeks. We also detected significant differences between sensory groups in repeated measures after 1 and 4 weeks in some pain intensity characteristics and patient-reported treatment effect scales. CONCLUSION QualST might be clinically applicable for detecting patient subgroups that could differ in the early treatment results of radicular pain by TFESI.
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Affiliation(s)
- Alfredas Vaitkus
- Clinic of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Jūratė Šipylaitė
- Clinic of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
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10
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Vascular compromise in a torsed transposed ulnar nerve case in support of intravenous contrast administration. Clin Imaging 2020; 70:118-123. [PMID: 33157368 DOI: 10.1016/j.clinimag.2020.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/08/2020] [Accepted: 10/01/2020] [Indexed: 11/23/2022]
Abstract
Nerve torsion is a recognized etiology in brachial and peripheral neuropathy. Vascular compromise of peripheral nerves is uncommon given their unique vascular supply. Preoperative imaging diagnosis of nerve torsion and vascular compromise can be made in some cases, which impacts treatment. We present a previously unreported case of long segment torsion and vascular compromise of the ulnar nerve following anterior subcutaneous transposition with a description of the imaging findings based on the unique structure of the nerve and the presence of a blood nerve barrier (BNB) and a discussion of the potential vulnerability of a transposed and torsed nerve.
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11
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Tampin B, Slater H, Jacques A, Lind CRP. Association of quantitative sensory testing parameters with clinical outcome in patients with lumbar radiculopathy undergoing microdiscectomy. Eur J Pain 2020; 24:1377-1392. [PMID: 32383177 PMCID: PMC7496563 DOI: 10.1002/ejp.1586] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 03/04/2020] [Accepted: 04/29/2020] [Indexed: 12/25/2022]
Abstract
Background/Aim This study aimed to establish the somatosensory profile of patients with lumbar radiculopathy at pre‐and post‐microdiscectomy and to explore any association between pre‐surgical quantitative sensory test (QST) parameters and post‐surgical clinical outcomes. Methods A standardized QST protocol was performed in 53 patients (mean age 38 ± 11 years, 26 females) with unilateral L5/S1 radiculopathy in the main pain area (MPA), affected dermatome and contralateral mirror sites and in age‐ and gender‐,and body site‐matched healthy controls. Repeat measures at 3 months included QST, the Oswestry Disability Index (ODI) and numerous other clinical measures; at 12 months, only clinical measures were repeated. A change <30% on the ODI was defined as ‘no clinically meaningful improvement’. Results Patients showed a significant loss of function in their symptomatic leg both in the dermatome (thermal, mechanical, vibration detection p < .002), and MPA (thermal, mechanical, vibration detection, mechanical pain threshold, mechanical pain sensitivity p < .041) and increased cold sensitivity in the MPA (p < .001). Pre‐surgical altered QST parameters improved significantly post‐surgery in the dermatome (p < .018) in the symptomatic leg and in the MPA (p < .010), except for thermal detection thresholds and cold sensitivity. Clinical outcomes improved at 3 and 12 months (p < .001). Seven patients demonstrated <30% change on the ODI at 12 months. Baseline loss of function in mechanical detection in the MPA was associated with <30% change on the ODI at 12 months (OR 2.63, 95% CI 1.09–6.37, p = .032). Conclusion Microdiscectomy resulted in improvements in affected somatosensory parameters and clinical outcomes. Pre‐surgical mechanical detection thresholds may be predictive of clinical outcome. Significance This study documented quantitative sensory testing (QST) profiles in patients with lumbar radiculopathy in their main pain area (MPA) and dermatome pre‐ and post‐microdiscectomy and explored associations between QST parameters and clinical outcome. Lumbar radiculopathy was associated with loss of function in modalities mediated by large and small sensory fibres. Microdiscectomy resulted in significant improvements in loss of function and clinical outcomes in 85% of our cohort. Pre‐surgical mechanical detection thresholds in the MPA may be predictive of clinical outcome.
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Affiliation(s)
- Brigitte Tampin
- Department of Physiotherapy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Neurosurgical Service of Western Australia, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Helen Slater
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Angela Jacques
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia.,Department of Research, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Christopher R P Lind
- Neurosurgical Service of Western Australia, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Medical School, University of Western Australia, Perth, Western Australia, Australia
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12
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Shi Y, Zou Y, Feng Y, Dou W, Ding H, Wang C, Zhao F, Shi H. A quantitative and clinical evaluation of nerve roots in lumbosacral radiculopathy using diffusion tensor imaging. Jpn J Radiol 2019; 38:222-230. [PMID: 31865529 DOI: 10.1007/s11604-019-00913-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 12/15/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE This study aimed to investigate the relationship between the fractional anisotropy (FA) values of compressed nerves derived in diffusion tensor imaging (DTI) and the corresponding clinical symptoms for quantitative and clinical evaluation in patients with lumbosacral radiculopathy. METHODS Thirty-six patients and ten volunteers participated in the study and measured with DTI. The resultant FA values for L5-S1 lumbar nerve roots were calculated at three sub-regions. Additionally, the DTI relevant tractography was also performed on L4-S1 nerve roots. Clinical symptoms were performed by Japanese Orthopedic Association (JOA) scoring for each patient and volunteer. RESULTS The FA values of the nerves at the symptomatic side were significantly lower than those at the asymptomatic side (p < 0.001). Diffusion tensor tractography distinctly showed abnormalities in the symptomatic nerve tracts. There was a significant correlation between JOA scores and the FA values of the compressed nerves at middle and distal sub-regions (p < 0.005). CONCLUSION The clinical symptoms associated robustly with the DTI derived FA values of the compressed nerves in patients with lumbosacral radiculopathy. Therefore, the FA values can be a potential clinical tool to evaluate the nerve roots in lumbosacral radiculopathy quantitatively.
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Affiliation(s)
- Yin Shi
- The Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Yuefen Zou
- The Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Yang Feng
- The Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Weiqiang Dou
- GE Healthcare, MR Research, Beijing, People's Republic of China
| | - Hongyuan Ding
- The Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Chuanbing Wang
- The Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Feng Zhao
- The Department of Orthopedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - Haibin Shi
- The Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People's Republic of China.
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13
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Andrade Gomes S, Lowrie M, Targett M. Long-term outcome following lateral foraminotomy as treatment for canine degenerative lumbosacral stenosis. Vet Rec 2018; 183:352. [PMID: 30068695 DOI: 10.1136/vr.104741] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 04/23/2018] [Accepted: 07/06/2018] [Indexed: 11/03/2022]
Abstract
Lateral foraminotomy has been described as an effective surgical treatment for foraminal stenosis in the treatment of degenerative lumbosacral stenosis (DLSS) in dogs. Clinical records were reviewed from 45 dogs which had undergone lateral foraminotomy at the lumbosacral junction either alone or in combination with decompressive midline dorsal laminectomy. Short-term outcome at six weeks was assessed by the surgeon to be good (11.1 per cent) or excellent (88.9 per cent) in all 45 cases. Long-term outcome beyond six months for lumbosacral syndrome was assessed by the owner as excellent in all 34 cases for which follow-up was available despite recurrence in five cases. Recurrence of clinical signs was not related to re-establishment of foraminal compression at the surgical site when assessed on repeat MRI and was managed by either contralateral foraminotomy in one case or conservative management with excellent response. This study confirms lateral foraminotomy as an effective procedure in the management of DLSS-affected dogs suffering from foraminal stenosis and demonstrates that initial good short-term results are maintained long term despite some treatable recurrences. Lateral foraminotomy is an effective procedure when used appropriately in DLSS with foraminal stenosis either alone or in combination with midline dorsal laminectomy.
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Affiliation(s)
| | | | - Mike Targett
- School of Veterinary Medicine and Science, University of Nottingham, Loughborough, UK
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14
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Maher DP, Ding W, Singh S, Opalacz A, Fishman C, Houghton M, Ahmed S, Chen L, Mao J, Zhang Y. Thermal QST Phenotypes Associated with Response to Lumbar Epidural Steroid Injections: A Pilot Study. PAIN MEDICINE 2018; 18:1455-1463. [PMID: 28340251 DOI: 10.1093/pm/pnw364] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objective Response to lumbar epidural steroid injection in lumbar radicular pain varies. The purpose of this study is to characterize the changes in quantitative sensory testing (QST) phenotypes of subjects and compare the QST characteristics in patients who do respond to treatment of radicular pain with a lumbar epidural steroid injection (ESI). Design Prospective, observational pilot study. Setting Outpatient pain center. Methods Twenty subjects with a lower extremity (LE) radicular pain who were scheduled to have an ESI were recruited. At the visit prior to and four weeks following an ESI, subjects underwent QST measurements of both the affected LE and the contralateral unaffected UE. Results Following an ESI, nine subjects reported a greater than 30% reduction in radicular pain and 11 reported a less than 30% reduction in radicular pain. Subjects who had less than 30% pain reduction response (nonresponders) to an ESI had increased pre-injection warm sensation threshold (37.30 °C, SD = 2.51 vs 40.39, SD = 3.36, P = 0.03) and heat pain threshold (47.22 °C, SD = 1.38, vs 48.83 °C, SD = 2.10, P = 0.04). Further, the nonresponders also showed increased pre-injection warm sensation threshold as measured in the difference of warm sensation detection threshold difference in the affected limb and the unaffected arm (2.68 °C, SD = 2.92 vs 5.67 °C, SD = 3.22, P = 0.045). Other QST parameters were not affected. Conclusions The results show that the nonresponders to ESIs have increased detection threshold to heat pain and warm sensation, suggesting that a preexisting dysfunction in the C fibers in this group of subjects who can be detected by QST. Such altered QST characteristics may prognosticate the response to ESIs.
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Affiliation(s)
- Dermot P Maher
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Weihua Ding
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
| | - Sarabdeep Singh
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Arissa Opalacz
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
| | - Claire Fishman
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
| | - Mary Houghton
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Lucy Chen
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
| | - Jianren Mao
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
| | - Yi Zhang
- Division of Pain Medicine, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
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15
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Oba H, Tsutsumimoto T, Yui M, Kamanaka T, Ohta H, Kosaku H, Misawa H. A prospective study of recovery from leg numbness following decompression surgery for lumbar spinal stenosis. J Orthop Sci 2017; 22:670-675. [PMID: 28456353 DOI: 10.1016/j.jos.2017.04.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/04/2017] [Accepted: 04/08/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Residual leg numbness (LN) following lumbar surgery can lower patient satisfaction; however, prospective studies are sparse. The purpose of this study was to evaluate recovery from LN following decompression surgery for lumbar spinal stenosis (LSS). METHODS A total of 145 patients with LSS were enrolled. All patients underwent decompressive surgery, with or without spinal fusion, followed by a 12 month prospective follow-up. The degree of LN and leg pain (LP) was assessed using the visual analog scale (VAS), a patient-reported outcome measure. RESULTS Six patients dropped out, and we evaluated 139 patients (average age, 68.1 years). The average VAS-LN scores were 5.9 ± 2.6, 1.8 ± 2.3, 2.0 ± 2.5, 2.1 ± 2.6, 2.2 ± 2.5, and 2.1 ± 2.6, and the average VAS-LP scores were 5.7 ± 2.8, 1.2 ± 1.7, 0.9 ± 1.5, 1.4 ± 2.0, 1.4 ± 2.0, and 1.4 ± 1.9 preoperatively and at 2 weeks, 3, 6, 9, 12 months following the surgery, respectively. Significant improvement in VAS-LN and VAS-LP scores was observed during the first 2 weeks after the surgery. At 12 months after the surgery, the VAS-LN score was significantly greater than the VAS-LP score. The change in the VAS-LN score between the preoperative and 12 month-postoperative values was significantly smaller than that in the VAS-LP score. Multivariate logistic analyses revealed that preoperative symptom duration and preoperative dural sac cross-sectional area (DCSA) were the significant independent predictive factors for residual LN. CONCLUSIONS Following lumbar decompression surgery, LN improved significantly during the first 2 weeks after surgery. However, the improvement in the VAS-LN score was less than in the VAS-LP score. Patients with longer preoperative symptom duration and narrow preoperative DCSA showed less LN improvement. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Hiroki Oba
- Department of Orthopaedic Surgery, Shinshu University, School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Takahiro Tsutsumimoto
- Department of Orthopaedic Surgery, Yodakubo Hospital, 2857 Nagawa Thisagata-gun, Nagano 386-0603, Japan.
| | - Mutsuki Yui
- Department of Orthopaedic Surgery, Yodakubo Hospital, 2857 Nagawa Thisagata-gun, Nagano 386-0603, Japan
| | - Takayuki Kamanaka
- Department of Orthopaedic Surgery, Shinshu University, School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Hiroshi Ohta
- Department of Orthopaedic Surgery, Yodakubo Hospital, 2857 Nagawa Thisagata-gun, Nagano 386-0603, Japan
| | - Hidemi Kosaku
- Department of Orthopaedic Surgery, Yodakubo Hospital, 2857 Nagawa Thisagata-gun, Nagano 386-0603, Japan
| | - Hiromichi Misawa
- Department of Orthopaedic Surgery, Yodakubo Hospital, 2857 Nagawa Thisagata-gun, Nagano 386-0603, Japan
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16
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Churyukanov MV, Shevtsova GE, Zagorulko OI. [A neuropathic component of lumboischialgia: mechanisms of development and treatment approaches]. Zh Nevrol Psikhiatr Im S S Korsakova 2017. [PMID: 28635877 DOI: 10.17116/jnevro20171171190-96] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Low back pain (LBP) is accompanied by the development of pain syndrome that spreads into the leg in 25-57% of patients. This is an important factor predicting the risk of transition of pain from acute to chronic and is an indirect indicator of disease severity. It is often impossible to specify the primary mechanism facilitated pain irradiation in lumboischialgia because many structures can cause analogous symptoms. Mechanisms of development of LBP are represented by nociceptive, neuropathic and psychogenic components. Currently, the term 'neuropathic back pain' remains rather ambiguous. Existing data suggest that the term 'neuropathic LBP is not confined to classic radiculopathy and is realized through several pathophysiological mechanisms. Lumboischialgia is a clinical appearance of these mechanisms. The authors present main mechanisms of the development of lumboischialgia, discuss clinical markers of neuropathic component of LBP, approaches to its diagnosis and treatment.
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Affiliation(s)
- M V Churyukanov
- Sechenov First Moscow State Medical University, Moscow; Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - G E Shevtsova
- Sechenov First Moscow State Medical University, Moscow
| | - O I Zagorulko
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
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17
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Kobayashi S, Suzuki Y, Meir A, Al-Khudairi N, Nakane T, Hayakawa K. Circulatory dynamics of the cauda equina in lumbar canal stenosis using dynamic contrast-enhanced magnetic resonance imaging. Spine J 2015; 15:2132-41. [PMID: 25998328 DOI: 10.1016/j.spinee.2015.05.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 04/20/2015] [Accepted: 05/07/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT There has been no study regarding the cauda equina circulation of patients with neurogenic intermittent claudication (NIC) in lumbar spinal canal stenosis (LSCS) using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). PURPOSE The mechanism responsible for the onset of NIC was investigated using DCE-MRI to examine changes in cauda equina blood flow in patients with LSCS. STUDY DESIGN This was a retrospective longitudinal registry and magnetic resonance imaging study. PATIENT SAMPLE The subjects consisted of 23 patients who had LSCS associated with NIC (stenosis group). Ten asymptomatic volunteers who did not have NIC served as controls (control group). In the LSCS group, the cross-sectional area of the dural sac was <75 mm2 at the site of most severe stenosis. These patients were further divided into single and double stenosis subgroups. OUTCOME MEASURES The main measures we used were the signal intensity (S-I) ratio and the shape and size of the time intensity (T-I) curves. We compared these between the stenosis and control groups. METHODS At first, plain T1-weighted MR images were obtained and the lumbar dural sac cross-sectional area was measured using a digitizer. For DCE-MRI, sagittal T1-weighted images of the same slice were acquired continuously for 10 minutes after administration of gadolinium as an intravenous bolus to observe the distribution of contrast medium (gadolinium) in the cauda equina. To objectively evaluate changes in contrast enhancement of the cauda equina at the site of canal stenosis, regions of interest were established. The signal intensity (SI) ratio was calculated to compare the signal intensities before and after contrast enhancement, and time-intensity curves were prepared to investigate changes over time. RESULTS The static imaging findings and the changes of gadolinium uptake showed striking differences between the study and control patients. In the stenosis group, abnormal intrathecal enhancement showed around the site of stenosis on enhanced MR imaging. The SI ratio at the site of canal stenosis had a slower increase in the arterial phase when compared with that in the control group and remained high in the venous phase for up to 10 minutes. Finally, abnormal intrathecal enhancement was visible around the site of stenosis on enhanced MR imaging in all patients. CONCLUSIONS These clinical data indicate that cauda equina nerve roots in the LSCS patients are pathologic even when symptoms are not elicited in the supine position, suggesting that intraradicular venous congestion and edema themselves do not influence the existence of radicular symptoms.
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Affiliation(s)
- Shigeru Kobayashi
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medicine, University of Fukui, 23-3, Shimoaizuki, Matsuoka, Eiheiji, Fukui 910-1193, Japan; Research and Education Program for Life Science, University of Fukui, Fukui, Japan.
| | - Yoshihiko Suzuki
- Suzuki Orthopaedic Clinic, 5-1, Tokiguchi, Nakamati, Toki, Gifu, 509-5124, Japan
| | - Adam Meir
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Naji Al-Khudairi
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Takashi Nakane
- Department of Radiology and Orthopaedics, Aiko Orthopaedic Hospital, 1221, Sinmei, Okehazama, Midori, Aichi, 458-0911, Japan
| | - Katsuhiko Hayakawa
- Department of Radiology and Orthopaedics, Aiko Orthopaedic Hospital, 1221, Sinmei, Okehazama, Midori, Aichi, 458-0911, Japan
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18
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Li Y, Zhang X, Kong Z, Huang W, Wang G. Kirschner wire is more effective than the nerve root retractor in treating patients with disc herniation. Clin Neurol Neurosurg 2015; 139:51-5. [PMID: 26368268 DOI: 10.1016/j.clineuro.2015.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 08/28/2015] [Accepted: 09/01/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To investigate the value of using Kirschner wire in the intraspinal procedures. METHODS From May 2011 to October 2013, a total of 46 patients with a single-level lumbar disc herniation with concomitant lumbar instability were randomly assigned to two groups at the time of admission. Group 1 had 23 patients who underwent posterior lumbar fusion using a nerve root retractor to drag nerve root, and Group 2 also had 23 patients who underwent the same operation by fixing Kirschner wires in the vertebral body to drag nerve root. All of these patients were assessed with visual analog scales (VAS) and Japanese Orthopaedic Association (JOA) scores before surgery, and were followed up at the time points of one week (VAS score only), three, six, and twelve months respectively after surgery. The actual retraction time of the nerve root of each patient was also recorded during the operation. RESULTS The differences in VAS and JOA scores were not significant between Group 1 and 2 before surgery. However, these scores showed significant improvement in Group 2 at one week and three months after surgery compared with those in Group 1. At six and twelve month follow-up time points, no significant difference was observed between these two groups. However, the retraction time of the nerve root of the patients in Group 2 was significantly shorter than in Group 1. CONCLUSIONS Using Kirschner wires instead of the nerve root retractor to pull nerve root in the patients with a single-level lumbar disc herniation accompanied by the lumbar instability is more effective in reducing the dragging damage of the nerve root at early phases after surgery and in shortening retraction time.
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Affiliation(s)
- Yetian Li
- Department of Orthopaedics, No. 2 People's Hospital of Wuhu, China
| | - Xiaohai Zhang
- Department of Orthopaedics, No. 2 People's Hospital of Wuhu, China
| | - Zhiyang Kong
- Department of Orthopaedics, No. 2 People's Hospital of Wuhu, China
| | - Wenjun Huang
- Department of Orthopaedics, No. 2 People's Hospital of Wuhu, China
| | - Guangye Wang
- Department of Orthopaedics, No. 2 People's Hospital of Wuhu, China.
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19
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Shi Y, Zong M, Xu X, Zou Y, Feng Y, Liu W, Wang C, Wang D. Diffusion tensor imaging with quantitative evaluation and fiber tractography of lumbar nerve roots in sciatica. Eur J Radiol 2015; 84:690-5. [DOI: 10.1016/j.ejrad.2015.01.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 01/03/2015] [Accepted: 01/06/2015] [Indexed: 11/28/2022]
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20
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Kobayashi S. Pathophysiology, diagnosis and treatment of intermittent claudication in patients with lumbar canal stenosis. World J Orthop 2014; 5:134-45. [PMID: 24829876 PMCID: PMC4017306 DOI: 10.5312/wjo.v5.i2.134] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 12/17/2013] [Accepted: 03/03/2014] [Indexed: 02/06/2023] Open
Abstract
Spinal nerve roots have a peculiar structure, different from the arrangements in the peripheral nerve. The nerve roots are devoid of lymphatic vessels but are immersed in the cerebrospinal fluid (CSF) within the subarachnoid space. The blood supply of nerve roots depends on the blood flow from both peripheral direction (ascending) and the spinal cord direction (descending). There is no hypovascular region in the nerve root, although there exists a so-called water-shed of the bloodstream in the radicular artery itself. Increased mechanical compression promotes the disturbance of CSF flow, circulatory disturbance starting from the venous congestion and intraradicular edema formation resulting from the breakdown of the blood-nerve barrier. Although this edema may diffuse into CSF when the subarachnoid space is preserved, the endoneurial fluid pressure may increase when the area is closed by increased compression. On the other hand, the nerve root tissue has already degenerated under the compression and the numerous macrophages releasing various chemical mediators, aggravating radicular symptoms that appear in the area of Wallerian degeneration. Prostaglandin E1 (PGE1) is a potent vasodilator as well as an inhibitor of platelet aggregation and has therefore attracted interest as a therapeutic drug for lumbar canal stenosis. However, investigations in the clinical setting have shown that PGE1 is effective in some patients but not in others, although the reason for this is unclear.
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21
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Abstract
Narrowing of the spinal canal or foramina is a common finding in spine imaging of the elderly. Only when symptoms of neurogenic claudication and/or cervical myelopathy are present is a spinal stenosis diagnosis made, either of the lumbar spine, cervical spine or both (only very rarely is the thoracic spine involved). Epidemiological data suggest an incidence of 1 case per 100 000 for cervical spine stenosis and 5 cases per 100 000 for lumbar spine stenosis. Cervical myelopathy in patients over 50 years of age is most commonly due to cervical spine stenosis. Symptomatic spinal narrowing can be congenital, or, more frequently, acquired. The latter may be the result of systemic illneses, namely endocrinopathies (such as Cushing disease or acromegaly), calcium metabolism disorders (including hyporarthyroidism and Paget disease), inflammatory diseases (such as rheumathoid arthritis) and infectious diseases. Physical examination is more often abnormal in cervical spondylotic myeloptahy whereas in lumbar spinal stenosis it is typically normal. Therefore spinal stenosis diagnosis relies on the clinical picture corresponding to conspicuous causative changes identified by imaging techniques, most importantly CT and MRI. Other ancillary diagnostic tests are more likely to be yielding for establishing a differential diagnosis, namely vascular claudication. Most patients have a progressive presentation and are offered non operative management as first treatment strategy. Surgery is indicated for progressive intolerable symptoms or, more rarely, for the neurologically catastrophic initial presentations. Surgical strategy consists mainly of decompression (depending on the anatomical level and type of narrowing: laminectomy, foraminotomy, discectomy, corporectomy) with additional instrumentation should spinal stability and sagittal balance be at risk. For cervical spine stenosis the main objective of surgery is to halt disease progression. There is class 1b evidence that surgery is of benefit for lumbar stenosis at least in the short term.
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Affiliation(s)
- João Levy Melancia
- Department of Neurosurgery, Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal
| | | | - João Lobo Antunes
- Department of Neurosurgery, Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal.
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22
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Dallaudière B, Lincot J, Hess A, Balbi V, Cornelis F, Larbi A, Laissy JP, Cotten A, Schouman-Claeys E. Clinical relevance of diffusion tensor imaging parameters in lumbar disco-radicular conflict. Diagn Interv Imaging 2013; 95:63-8. [PMID: 24161286 DOI: 10.1016/j.diii.2013.08.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To measure the fractional anisotropy (FA) and the mean diffusivity (MD) values of L4, L5 and S1 nerve roots using diffusion tensor imaging (DTI) and to correlate them with four different clinical patterns. PATIENTS AND METHODS Fifty-six human participants were prospectively included and divided between four groups: healthy subjects, patients with clinical symptomatic nerve root pain with and without anatomical discoradicular conflict and patients with incidental anatomical discoradicular conflict seen on magnetic resonance imaging (MRI). MRI protocol included anatomical sequences (sagittal T1- and T2-weighted, axial T2-weighted) and a 25 directions DTI sequence. FA and MD values were measured in consensus by two readers and compared between the four groups. RESULTS Mean FA and MD values were significantly different for patients with clinically symptomatic nerve root pain (n=27) both with (n=16) (FA=0.187±0.015; MD=510±40) and without (n=11) (FA=0.193±0.011; MD=490±30.5) anatomical discoradicular conflict compared to healthy subjects (n=29) (FA=0.221±0.011; MD=460.9±35.5) including 2 subjects with incidental anatomical discoradicular conflict (FA=0.211±0.013; MD=450.8±41.2) on MRI (P=0.003). CONCLUSION Measurement of FA and MD values of L4, L5 and S1 nerve roots using DTI could be useful in lumbar nerve root pain assessment. Further studies with different image processing methods are needed.
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Affiliation(s)
- B Dallaudière
- Service de Radiologie, Centre Hospitalier Universitaire Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75018 Paris, France; Inserm U698, Centre Hospitalier Universitaire Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75018 Paris, France; Faculté de Médecine Xavier-Bichat, Université Paris-7, Paris, France.
| | - J Lincot
- Service de Radiologie, Centre Hospitalier Universitaire Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75018 Paris, France
| | - A Hess
- Service de Radiologie, Centre Hospitalier Universitaire Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75018 Paris, France; Faculté de Médecine Xavier-Bichat, Université Paris-7, Paris, France
| | - V Balbi
- Service de Radiologie Ostéo-Articulaire, Centre Hospitalier Régional Universitaire Roger-Salengro, Lille, France; Faculté de Médecine, Université Lille 2, Lille, France
| | - F Cornelis
- Service d'Imagerie Diagnostique et Interventionnelle de l'Adulte Groupe Hospitalier Pellegrin, place Amelie-Raba-Leon, 33076 Bordeaux cedex, France
| | - A Larbi
- MSK Department Imaging, Cliniques Universitaires Saint-Luc, avenue Hippocrate 10, 1200 Bruxelles, Belgique
| | - J-P Laissy
- Service de Radiologie, Centre Hospitalier Universitaire Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75018 Paris, France; Faculté de Médecine Xavier-Bichat, Université Paris-7, Paris, France
| | - A Cotten
- Service de Radiologie Ostéo-Articulaire, Centre Hospitalier Régional Universitaire Roger-Salengro, Lille, France; Faculté de Médecine, Université Lille 2, Lille, France
| | - E Schouman-Claeys
- Service de Radiologie, Centre Hospitalier Universitaire Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75018 Paris, France; Faculté de Médecine Xavier-Bichat, Université Paris-7, Paris, France
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Abstract
STUDY DESIGN Exposure to nucleus pulposus and displacement of intraspinal nervous structures with assessment of spontaneous behavioral changes in rats. OBJECTIVE To develop a controlled, experimental model for nerve root injury. SUMMARY OF BACKGROUND DATA There are a number of experimental models presented for studies on radiculopathies. One frequently used model is based on exposure to nucleus pulposus and displacement of the dorsal root ganglion (DRG). However, it is clinically more common that the nerve roots are displaced/compressed than the DRG. In this study, we developed a model for displacement of the nerve root by modifying the DRG model. METHODS After removing the left L3-L4 facet joint, the underlying disc was punctured, and the L4 nerve root was displaced laterally by an injection needle (n = 10). In sham experiments, the same procedure was performed without disc puncture and displacement (n = 10). In 10 rats, the left L4-L5 facet joint was removed. The underlying disc was punctured and the L4 DRG was displaced medially by an injection needle. Assessment of spontaneous behavioral changes was performed on days 1, 3, 7, 14, and 21, postsurgery. RESULTS There was a clear increase in duration of the behavior "unloading of the paw" after displacement of the DRG that was most pronounced on day 1 and then gradually declined. There was a similar pattern for this behavior induced by nerve root displacement, although the duration was higher than that for the DRG displacement. No apparent trends in behavioral changes were observed for the other behaviors studied. CONCLUSION Displacement of the nerve root induced more changes in the pain behavior than displacement of the DRG, but only for the behavior unloading of the paw. Because nerve root injury is more common than DRG injury, this model may be more clinically relevant than the DRG model. LEVEL OF EVIDENCE N/A.
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Wu Q, Inman RD, Davis KD. Neuropathic pain in ankylosing spondylitis: a psychophysics and brain imaging study. ACTA ACUST UNITED AC 2013; 65:1494-503. [PMID: 23460087 DOI: 10.1002/art.37920] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 02/26/2013] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine whether there is a neuropathic component in ankylosing spondylitis (AS) back pain and to delineate gray matter brain abnormalities associated with AS. METHODS Seventeen patients with back pain secondary to AS who were not receiving biologic agents and 17 age- and sex-matched healthy controls consented to participate in the study and were assessed using the painDETECT instrument (scores of ≤12 indicating low probability of neuropathic pain) and the McGill Pain Questionnaire. Mechanical and thermal thresholds were determined in all subjects, and brain gray matter was assessed by 3T magnetic resonance imaging. RESULTS Eleven of the 17 AS patients had painDETECT scores of >12. The patients had decreased mechanical and cold sensitivity on the dorsum of their feet but did not have altered pain thresholds. Compared to controls, the AS patients exhibited cortical thinning in the primary somatosensory, insular, anterior cingulate, and anterior mid-cingulate cortices and the supplemental motor area, and increased gray matter volume in the thalamus and putamen. Scores on the painDETECT in AS patients were correlated with decreased gray matter in the primary somatosensory cortex and with increased gray matter in the motor cortex, anterior cingulate cortex, prefrontal cortex, thalamus, and striatum. CONCLUSION The present findings indicate that neuropathic pain occurs in AS. Furthermore, abnormal brain gray matter and neural correlates of neuropathic pain are concordant with the clinical picture of AS, which includes sensorimotor and mood deficits as well as neuropathic pain symptoms. These results suggest that back pain in AS is a mixed pain condition that includes a neuropathic pain component.
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Affiliation(s)
- Qi Wu
- Toronto Western Research Institute at Toronto Western Hospital, Toronto, Ontario, Canada
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25
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Bartynski WS, Jennings RB, Rothfus WE, Agarwal V. Immediate pain response to interlaminar lumbar epidural steroid administration: response characteristics and effects of anesthetic concentration. AJNR Am J Neuroradiol 2013; 34:239-46. [PMID: 22766680 DOI: 10.3174/ajnr.a3170] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Interlaminar LESIs are commonly used to treat LBP or radiculopathy. Most studies focus on the long-term outcomes of LESI. The purpose of this study is to evaluate the immediate effects of fluoroscopically guided LESI on LBP/radiculopathy including low- or high-strength anesthetic response. MATERIALS AND METHODS The procedure notes, post-procedure records, and imaging records dedicated spine nurse assessments, and imaging records were retrospectively evaluated in 392 fluoroscopically guided LESIs performed in 276 patients (nonrandomized, nonblinded; 131 males, 145 females; average age, 56 years) with LBP/radiculopathy using either low- or high-strength anesthetic (80 mg of methylprednisilone mixed with bupivacaine [0.25% or 0.5%]). Post-procedure documentation of the patient's pre- and postprocedure VAS pain-scale level were tabulated. RESULTS Single LESI was performed in 199 patients, with multiple LESIs in 77 (193 injections). Low-strength bupivacaine (0.25%) was used in 237 injections, with high-strength (0.5%) in 155. Complete to near-complete immediate pain relief (<20% residual pain) was reported after 197 of 392 (50.3%) injections. No pain relief was reported after 60 (15.4%) injections (>80% residual), with partial relief in the remainder. No statistical difference was noted between low- and high-anesthetic strength or between single- and multiple-injection patients. In multiple-LESI patients, consistent pain relief response was noted in 39 of 77 (50.6%) patients, with improving LESI response in 20.8%, deteriorating LESI response in 19.5%, and variable response in 9.1%. CONCLUSIONS An immediate pain-extinction response is identified after LESI, which appears independent of anesthetic strength. This observation may relate to pain origin and/or pain nociceptor afferent pathway in an individual patient and potentially relate to treatment response.
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Affiliation(s)
- W S Bartynski
- Department of Radiology, Division of Neuroradiology, Presbyterian University Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.
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Anti-inflammatory and analgesic effects of Yaotuitong Capsules in experimental rats with chemically induced radicular neuritis. J TRADIT CHIN MED 2012; 32:437-41. [DOI: 10.1016/s0254-6272(13)60051-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Balbi V, Budzik JF, Duhamel A, Bera-Louville A, Le Thuc V, Cotten A. Tractography of lumbar nerve roots: initial results. Eur Radiol 2011; 21:1153-9. [DOI: 10.1007/s00330-010-2049-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Revised: 11/09/2010] [Accepted: 11/12/2010] [Indexed: 10/18/2022]
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Schäfer A, Hall T, Müller G, Briffa K. Outcomes differ between subgroups of patients with low back and leg pain following neural manual therapy: a prospective cohort study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2010; 20:482-90. [PMID: 21116662 DOI: 10.1007/s00586-010-1632-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Revised: 08/17/2010] [Accepted: 11/07/2010] [Indexed: 10/18/2022]
Abstract
The objective is to determine if pain and disability outcomes of patients treated with neural mobilisation differ for sub-classifications of low back and leg pain (LB&LP). Radiating leg pain is a poor prognostic factor for recovery in patients with LBP. To improve outcome, a new pathomechanism-based classification system was proposed: neuropathic sensitization (NS), denervation (D), peripheral nerve sensitization (PNS) and musculoskeletal (M). Seventy-seven patients with unilateral LB&LP were recruited. Following classification, all subjects were treated seven times with neural mobilisation techniques. A successful outcome was defined as achieving a minimal clinically important change in pain intensity (11-point numerical rating scale), physical function (Roland Morris disability questionnaire) and global perceived change (7-point Likert scale: from 1 = "completely recovered" to 7 = "worse than ever"). The proportion of responders was significantly greater in PNS (55.6%) than the other three groups (NS 10%; D 14.3% and M10%). After adjusting for baseline differences, mean magnitude of improvement of the outcome measures were significantly greater in PNS compared to the other groups. Patients classified as PNS have a more favourable prognosis following neural mobilisation compared to the other groups.
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Affiliation(s)
- Axel Schäfer
- Faculty of Social Work and Health, Degree Programmes for Occupational Therapy, Speech and Language Therapy & Physiotherapy, HAWK University of Applied Science and Arts, Goschentor 1, 31134 Hildesheim, Germany.
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Kobayashi S, Takeno K, Yayama T, Awara K, Miyazaki T, Guerrero A, Baba H. Pathomechanisms of sciatica in lumbar disc herniation: effect of periradicular adhesive tissue on electrophysiological values by an intraoperative straight leg raising test. Spine (Phila Pa 1976) 2010; 35:2004-14. [PMID: 20959779 DOI: 10.1097/brs.0b013e3181d4164d] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN This study is aimed to investigate the changes of nerve root functions during the straight leg raising (SLR) test in vivo. OBJECTIVE To investigate the relationship between nerve root movement and the electrophysiological values during an intraoperative SLR test. SUMMARY OF BACKGROUND DATA The SLR test is one of the most significant signs for making a clinical diagnosis of lumbar disc herniation. A recent study showed that intraradicular blood flow apparently decreased during the SLR test in patients with disc herniation. METHODS The study included 32 patients who underwent microdiscectomy. During the surgery, the nerve root motion affected by the hernia was observed during the SLR test. The patients' legs were allowed to hang down to the angle at which sciatica had occurred and the change of nerve root action potentials was measured. After removal of the hernia, a similar procedure was repeated. The periradicular specimens collected during surgery were examined by light and electron microscope. RESULTS In all patients intraoperative microscopy revealed that the hernia was adherent to the dura mater of the nerve roots. During the SLR test, the limitation of nerve root movement occurred by periradicular adhesive tissue and amplitude of action potential showed a sharp decrease at the angle that produced sciatica. After removal of the hernia, all the patients showed smooth gliding of the nerve roots during the test, and there was no marked decrease of amplitude. Our data suggest that temporary ischemic changes in the nerve root cause transient conduction disturbances. Pathologic examination showed that the periradicular tissue consisted of the granulation with vascularization and many inflammatory cell infiltrations. CONCLUSION The presence of periradicular fibrosis will compound the nerve root pain by fixing the nerve in one position, thereby increasing the susceptibility of the nerve root to tension or compression.
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Affiliation(s)
- Shigeru Kobayashi
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, The University of Fukui, Fukui, Japan.
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Kobayashi S, Mwaka ES, Meir A, Uchida K, Kokubo Y, Takeno K, Miyazaki T, Nakajima H, Kubota M, Shimada S, Baba H. Changes in blood flow, oxygen tension, action potentials, and vascular permeability induced by arterial ischemia or venous congestion on the lumbar dorsal root ganglia in dogs. J Neurotrauma 2010; 26:1167-75. [PMID: 19331518 DOI: 10.1089/neu.2008.0837] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
It is generally believed that radiculopathy associated with the degenerative conditions of the spine may result from both mechanical compression and circulatory disturbance. However, the basic pathophysiology of circulatory disturbance induced by ischemia and congestion is not fully understood. This study investigated the effect of ischemia and congestion on the dorsal root ganglion (DRG) using an in vivo model. The sixth and seventh lumbar laminae were removed and the seventh lumbar DRG was exposed using adult dogs. The aorta was clamped as an ischemic model in the DRG, and the inferior vena cava was clamped as a congestion model at the sixth costal level for 30 min using forceps transpleurally. Measurements of blood flow, partial oxygen pressure, and action potentials in the DRG were recorded over a period of 1 h after clamp release. Finally, we examined the status of intraganglionic blood permeability under a fluorescence microscope following injection of Evans blue albumin into the cephalic vein to determine the type of circulatory disturbance occurring in the DRG. Immediately after inferior vena cava clamping, the central venous pressure increased approximately four times and marked extravasation of protein tracers was induced in the lumbar DRG. Blood flow, partial oxygen pressures, and action potentials within the DRG were more severely affected by the aorta clamping; however, this ischemic model did not reveal any permeability changes in the DRG. The permeability change in the DRG was more easily increased via venous congestion than by arterial ischemia. The intraganglionic venous flow was stopped with compression at much lower pressures than that needed to impact arterial flow. From a clinical perspective, intraganglionic edema formation, rather than arterial ischemia, may be an earlier phenomenon inducing DRG dysfunction.
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Affiliation(s)
- Shigeru Kobayashi
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, The University of Fukui, Matsuoka, Fukui, Japan.
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Kobayashi S, Mwaka ES, Baba H, Kokubo Y, Yayama T, Kubota M, Nakajima H, Meir A. Microvascular system of the lumbar dorsal root ganglia in rats. Part II: neurogenic control of intraganglionic blood flow. J Neurosurg Spine 2010; 12:203-9. [PMID: 20121357 DOI: 10.3171/2009.8.spine08895] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The dorsal root ganglion (DRG) should not be overlooked when considering the mechanism of low-back pain and sciatica, so it is important to understand the morphological features of the vascular system supplying the DRG. However, the neurogenic control of intraganglionic blood flow has received little attention in the past. The authors used an immunohistochemical technique to investigate the presence and distribution of autonomic and sensory nerves in blood vessels of the DRG. METHODS Ten Wistar rats were used. To investigate the mechanism of vasomotion on the lumbar DRG, the authors used immunohistochemical methods. Sections were incubated overnight with antisera to tyrosine hydroxylase (TH), aromatic L-amino-acid decarboxylase (AADC), 5-hydroxytryptamine, substance P (SP), calcitonin gene-related peptide (CGRP), vasoactive intestinal peptide (VIP), somatostatin (SOM), neuropeptide Y (NPY), leucine-enkephalin, and cholineacetyl transferase (Ch-E). The avidin-biotin complex method was used as the immunohistochemical procedure, and the sections were observed under a light microscope. RESULTS In the immunohistochemical study, TH-, AADC-, SP-, CGRP-, VIP-, SOM-, NPY-, and Ch-E-positive fibers were seen within the walls of blood vessels in the DRG. This study revealed the existence of a comprehensive perivascular adrenergic, cholinergic, and peptidergic innervation of intraganglionic blood vessels, with a possible role in neurogenic regulation (autoregulation) of intraganglionic circulation. CONCLUSIONS The presence of perivascular nerve plexuses around intraganglionic microvessels suggests that autonomic nerves play an important role in intraganglionic circulation.
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Affiliation(s)
- Shigeru Kobayashi
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, The University of Fukui, Matsuoka, FukuiJapan
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Abstract
STUDY DESIGN This study is to investigate the changes of vasomotion of intraradicular microvessels in vivo. OBJECTIVE We have observed microvascular corrosion casts of the lumbar nerve root by scanning electron microscopy and used an immunohistochemical technique to investigate the presence and distribution of autonomic and sensory nerve in blood vessels of the nerve root. SUMMARY OF BACKGROUND DATA It is generally considered that the genesis of radiculopathy associated with the degenerative conditions of the spine may result from both mechanical compression and circulatory disturbance. However, the neurogenic control of intraradicular blood flow has received little attention in the past. METHODS For three-dimensional observation of intraradicular vessels, we used scanning electron microscopic examination of microvascular corrosion casts in ten Wister rats. To investigate the mechanism of vasomotion of the nerve root, we used immunohistochemical methods. The sections were incubated overnight with antisera to tyrosine hydroxylase, choline acetyl transferase, substance P, calcitonin-gene-related peptide, vasoactive intestinal peptide, somatostatin, neuropeptide Y, leucine-enkephalin, cholecystokinin octapeptide, brain-nitric oxide synthase, and endothelium-nitric oxide synthase. Abidin-biotin complex method was used as the immunohistochemical procedure and the sections were observed under the light microscope. RESULTS The general view of whole vascular casts of the lumbar spinal cord and nerve roots showed a high density of vessels. Bifurcation or anastomoses of capillaries approximately took place at right angles in a T-shaped pattern and capillaries showed a lot of ring-like compressions. This ring-like compression on the cast may represent a vascular sphincter in the microvessels. This study also reveals the existence of perivascular adrenergic, cholinergic, peptidergic, and nitroxydergic innervation with a possible role in neurogenic regulation of nerve root circulation. CONCLUSION Perivascular nerve plexuses around intraradicular microvessels suggest that the autonomic nerves play an important role in intraradicular circulation.
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Schäfer A, Hall T, Briffa K. Classification of low back-related leg pain—A proposed patho-mechanism-based approach. ACTA ACUST UNITED AC 2009; 14:222-30. [DOI: 10.1016/j.math.2007.10.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Revised: 09/30/2007] [Accepted: 10/04/2007] [Indexed: 01/19/2023]
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Ultrastructural analysis on lumbar disc herniation using surgical specimens: role of neovascularization and macrophages in hernias. Spine (Phila Pa 1976) 2009; 34:655-62. [PMID: 19333096 DOI: 10.1097/brs.0b013e31819c9d5b] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN The mechanisms responsible for the spontaneous regression of lumbar disc herniation (LDH) were studied by examining herniated tissue collected at operation from patients with LDH. OBJECTIVE The aim of the present study was to investigate the role of neovascularization and macrophages in hernias when spontaneous regression of LDH occurred. SUMMARY OF BACKGROUND DATA Spontaneous regression of LDHs has already been demonstrated by diagnostic imaging with tools such as magnetic resonance imaging. However, there have been few studies on the mechanisms of spontaneous regression based on pathologic examination of herniated tissue. In particular, there has been no detailed work on the role of macrophages, which are thought to be closely associated with spontaneous regression. METHODS The magnetic resonance imaging and operative findings of 73 patients who underwent surgery were investigated, and specimens collected during surgery were examined by light and transmission electron microscopy. RESULTS Capillaries that invade the hernia and macrophages derived from monocytes migrating out of these capillaries are considered to be important factors in the regression of the herniated disc. Macrophages contain lysosomes filled with collagen-degrading enzymes that break down substances after phagocytosis, whereas primary lysosomes are secreted by these cells and break down intercellular substances such as collagen. Both of these mechanisms are closely involved in the regression of herniation. CONCLUSION The inflammatory response that occurs around hernia tissue in the epidural space is believed to play an important role in herniated disc resorption, although it may also have a harmful effect on the adjacent nerve root. Therefore, control of the inflammatory reaction is an important challenge when treating patients with disc herniation.
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Amaya F, Samad TA, Barrett L, Broom DC, Woolf CJ. Periganglionic inflammation elicits a distally radiating pain hypersensitivity by promoting COX-2 induction in the dorsal root ganglion. Pain 2009; 142:59-67. [PMID: 19135800 PMCID: PMC2755568 DOI: 10.1016/j.pain.2008.11.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2007] [Revised: 11/20/2008] [Accepted: 11/21/2008] [Indexed: 12/19/2022]
Abstract
We have developed a model in which inflammation contiguous to and within a dorsal root ganglion (DRG) was generated by local application of complete Freund's adjuvant (CFA) to the L4 lumbar spinal nerve as it exits from the intervertebral foramen. The periganglionic inflammation (PGI) elicited a marked reduction in withdrawal threshold to mechanical stimuli and an increase in heat pain sensitivity in the ipsilateral hindpaw in the absence of any hindpaw inflammation. The pain sensitivity appeared within hours and lasted for a week. The PGI also induced a prominent increase in IL-1beta and TNF-alpha levels in the DRG and of cyclooxygenase-2 (COX-2) expression in neurons and satellite cells. A selective COX-2 inhibitor reduced the PGI-induced hyperalgesia. We also show that IL-1beta induces COX-2 expression and prostaglandin release in DRG neurons in vitro in a MAP kinase-dependent fashion. The COX-2 induction was prevented by ERK and p38 inhibitors. We conclude that periganglionic inflammation increases cytokine levels, including IL-1beta, leading to the transcription of COX-2 and prostaglandin production in the affected DRG, and thereby to the development of a dermatomally distributed pain hypersensitivity.
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Affiliation(s)
- Fumimasa Amaya
- Neural Plasticity Research Group, Department of Anesthesia and Critical Care, Massachusetts General Hospital and Harvard Medical School, USA
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Japan
| | - Tarek A. Samad
- Neural Plasticity Research Group, Department of Anesthesia and Critical Care, Massachusetts General Hospital and Harvard Medical School, USA
| | - Lee Barrett
- Neural Plasticity Research Group, Department of Anesthesia and Critical Care, Massachusetts General Hospital and Harvard Medical School, USA
| | - Daniel C. Broom
- Neural Plasticity Research Group, Department of Anesthesia and Critical Care, Massachusetts General Hospital and Harvard Medical School, USA
| | - Clifford J. Woolf
- Neural Plasticity Research Group, Department of Anesthesia and Critical Care, Massachusetts General Hospital and Harvard Medical School, USA
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Visualization of intraneural edema using gadolinium-enhanced magnetic resonance imaging of carpal tunnel syndrome. J Orthop Sci 2009; 14:24-34. [PMID: 19214684 DOI: 10.1007/s00776-008-1291-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2008] [Accepted: 10/06/2008] [Indexed: 10/20/2022]
Abstract
BACKGROUND In general, carpal tunnel syndrome (CTS) is diagnosed based mainly on clinical findings and electrophysiology. However, the pathological state of the compressed median nerve could not be shown on imaging. Gadolinium-enhanced magnetic resonance (MR) imaging may give us an idea about the status of the blood-nerve barrier of peripheral nerves. Therefore, detecting intraneural edema may be a way of diagnosing entrapment neuropathy. The present study investigated the diagnostic role of gadolinium-enhanced MR imaging of CTS. METHODS The subjects were 23 patients (34 hands) with idiopathic CTS. To serve as control subjects, 12 wrists of asymptomatic volunteers were studied. Using the spin-echo method, T1- and T2-weighted axial MR images were obtained. Intravenously injected gadolinium was used to obtain enhanced images. We studied the relation between nerve enhancement and the symptomatology. RESULTS After intravenous injection of gadolinium, there was no enhancement of the unaffected nerves in the carpal tunnels of the control group. Gadolinium enhancement was found in only 87% of patients with CTS who visited the hospital at an early stage and therefore had no nerve deficiency on electrophysiological studies (39%). Based on this finding, during the early stages when the nerve is in a state of neuropraxia, gadolinium-enhanced MR imaging of the median nerve might prove to be the most sensitive modality for detecting early nerve dysfunction. MR imaging also revealed a higher frequency of enhancement in the advanced stage of CTS with muscle atrophy. CONCLUSIONS We conclude that gadolinium-enhanced MR imaging can detect not only morphological changes but also pathological changes of the median nerve in patients with CTS. Currently, gadolinium-enhanced-MR imaging is probably most commonly used to image patients who have ambiguous electrodiagnostic studies and clinical examination in an early stage of CTS.
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Kobayashi S, Takeno K, Miyazaki T, Kubota M, Shimada S, Yayama T, Uchida K, Normura E, Mwaka E, Baba H. Effects of arterial ischemia and venous congestion on the lumbar nerve root in dogs. J Orthop Res 2008; 26:1533-40. [PMID: 18536056 DOI: 10.1002/jor.20696] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The development of radiculopathy in patients with lumbar canal stenosis is thought to be closely related to intraradicular edema resulting from compression. However, there is little agreement as to question which is more essential for intermittent claudication: ischemia or congestion. The aim of the present experimental investigation was to examine the effect of ischemia and congestion on the nerve root using dogs. The aorta was clamped as an ischemia model of the nerve root and the inferior vena cava was clamped as a congestion model at the sixth costal level for 30 min using forceps transpleurally. Measurements of blood flow, partial oxygen pressure, and conduction velocity in the nerve root were repeated over a period of 1 h after release of clamping. Finally, we examined the status of intraradicular blood-nerve barrier under fluorescence and transmission electron microscope. Immediately after clamping of the inferior vena cava, the central venous pressure increased by about four times and marked extravasation of protein tracers was induced in the lumbar nerve root. Blood flow, partial oxygen pressure, and conduction velocity of the nerve root were more severely affected by aorta clamp, but this ischemia model did not show any intraradicular edema. The blood-nerve barrier in the nerve root was more easily broken by venous congestion than by arterial ishemia. In conclusion, venous congestion may be an essential factor precipitating circulatory disturbance in compressed nerve roots and inducing neurogenic intermittent claudication.
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Affiliation(s)
- Shigeru Kobayashi
- Faculty of Medical Sciences, Department of Orthopaedics and Rebhailitation Medicine, The University of Fukui, 23-3 Shimozizuki, Matsuoka, Eiheiji, Fukui, Japan.
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Lee IH, Yoon YC, Cho EY, Kwon JW, Kwon ST. Perineural air injection as a means of prevention of thermal injury of the sciatic nerve during radio frequency ablation: a preliminary experimental study in rabbits. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2008; 27:1221-1227. [PMID: 18645081 DOI: 10.7863/jum.2008.27.8.1221] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE The purpose of this study was to determine whether perineural air injection before radio frequency (RF) ablation of thigh muscles can minimize thermal injury to the sciatic nerve. METHODS Eighteen percutaneous RF ablation procedures were performed in the thighs of 9 rabbits (control, n = 9, right thigh; experimental, n = 9, left thigh) with an internally cooled electrode (1-cm active tip). In the control group, the tip of the electrode was located in posterior muscles 5 mm away from the sciatic nerve before ablation. In the experimental group, sonographically guided air injection into the perineural space was performed just before ablation. Animals were killed 7 days after ablation, and the presence or absence of pathologic changes of the sciatic nerves (axonal necrosis, myelin digestion, endoneurial fibrosis, perineurial fibrosis, and dystrophic calcification) in both groups were compared under an optical microscope. RESULTS Perineural air injection was achieved successfully with a single puncture in all rabbits in the experimental group. All of the pathologic findings were observed much more frequently in the control group, and the differences in the frequencies of axonal necrosis and myelin digestion of the sciatic nerve between the groups were clinically significant (P < .05). CONCLUSIONS Perineural air injection may be useful for reducing the frequency of thermal injury during RF ablation of lesions adjacent to nerves.
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Affiliation(s)
- In Ho Lee
- Department of Radiology, Samsung Medical Center, School of Medicine, Sungkyunkwan University, 50 Ilwon-dong, Kangnam-ku, Seoul 135-710, Korea
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Tubbs RS, Louis RG, Wartmann CT, Lott R, Chua GD, Kelly D, Palmer CA, Shoja MM, Loukas M, Oakes WJ. Histopathological basis for neurogenic thoracic outlet syndrome. Laboratory investigation. J Neurosurg Spine 2008; 8:347-51. [PMID: 18377320 DOI: 10.3171/spi/2008/8/4/347] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT To the best of the authors' knowledge, no report exists that has demonstrated the histopathological changes of neural elements within the brachial plexus as a result of cervical rib compression. METHODS Four hundred seventy-five consecutive human cadavers were evaluated for the presence of cervical ribs. From this cohort, 2 male specimens (0.42%) were identified that harbored cervical ribs. One of the cadavers was found to have bilateral cervical ribs and the other a single right cervical rib. Following gross observations of the brachial plexus and, specifically, the lower trunk and its relationship to these anomalous ribs, the lower trunks were submitted for immunohistochemical analysis. Specimens were compared with two age-matched controls that did not have cervical ribs. RESULTS The compressed plexus trunks were largely unremarkable proximal to the areas of compression by cervical ribs, where they demonstrated epi- and perineurial fibrosis, vascular hyalinization, mucinous degeneration, and frequent intraneural collagenous nodules. These histological findings were not seen in the nerve specimens in control cadavers. The epineurium was thickened with intersecting fibrous bands, and the perineurium appeared fibrotic. Many of the blood vessels were hyalinized. The nerve fascicles contained frequent intraneural collagenous nodules in this area, and focal mucinous degeneration was identified. CONCLUSIONS Cervical ribs found incidentally may cause histological changes in the lower trunk of the brachial plexus. The clinician may wish to observe or perform further evaluation in such patients.
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Affiliation(s)
- R Shane Tubbs
- Department of Surgery, Division of Neurosurgery, University of Alabama at Birmingham, Alabama, USA.
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Synapse involvement of the dorsal horn in experimental lumbar nerve root compression: a light and electron microscopic study. Spine (Phila Pa 1976) 2008; 33:716-23. [PMID: 18379397 DOI: 10.1097/brs.0b013e318169500e] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This study was aimed at investigating changes in the dorsal horn of the lumbar cord induced by mechanical compression using an in vivo model. OBJECTIVE To determine the effect of axonal flow disturbance in the dorsal horns induced by nerve root compression. SUMMARY OF BACKGROUND DATA Few studies have looked at changes of synapses within the dorsal horn caused by disturbance of axonal flow and the axon reaction as a result of mechanical compression of the dorsal root. METHODS In mongrel dogs, the 7th lumbar nerve root was compressed for 1 week, or 3 weeks using a clip. After intravenous injection of Evans blue albumin, they were observed under a fluorescence microscope for the purpose of clarifying the function of the blood-spinal cord barrier. Morphologic changes of the synapses in the dorsal horns secondary to the nerve fiber degeneration were examined by light and electron microscope. Changes on immuno-staining for substance P, calcitonin gene-related peptide, and somatostatin in the dorsal horn were also examined. RESULTS Light microscope observation conducted 1 week after compression of the nerve roots revealed Wallerian degeneration of the myelinated nerve in the dorsal horn, and fluorescence microscope observation of these areas demonstrated edema formation resulting from damage of the blood-spinal cord barrier. Three weeks after the compression, electron microscope observation revealed shrinkage of the axon terminals, ubiquitous presence of high electron density degeneration and presence of synapses whose contact with synapses was disrupted. Immuno-histochemical studies showed a marked decrease of substance P, calcitonin gene-related peptide, and somatostatin staining in substance gelatinosa with Wallerian degeneration after compression of nerve root. CONCLUSION It is important to recognize that compressive disturbance of the nerve roots caused Wallerian degeneration not only at the site of compression of nerve roots but also at the synapses of spinal cord dorsal horns.
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Freynhagen R, Rolke R, Baron R, Tölle TR, Rutjes AK, Schu S, Treede RD. Pseudoradicular and radicular low-back pain – A disease continuum rather than different entities? Answers from quantitative sensory testing. Pain 2008; 135:65-74. [PMID: 17570589 DOI: 10.1016/j.pain.2007.05.004] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2006] [Revised: 04/18/2007] [Accepted: 05/02/2007] [Indexed: 01/21/2023]
Abstract
To assess whether pseudoradicular low-back pain may be associated with subclinical sensory deficits in the distal extremity, we applied the quantitative sensory testing protocol of the German Research Network on Neuropathic Pain (DFNS) in 15 patients with pseudoradicular pain distribution. Sixteen age- and gender-matched healthy control subjects as well as 12 patients with radicular pain syndromes (L4-S1) were studied with the same protocol. Radicular pain was diagnosed using clinical criteria (pain radiation beyond the knee, motor-, sensory-, or reflex deficits, positive Laségue's test). Z-score QST profiles revealed a selective loss of vibration detection, detection of v. Frey hair contact, and cold detection in the affected dermatomes in the radicular pain group. The contralateral dermatome was also affected, but to a lesser degree. In patients with pseudoradicular pain, the sensory profile was similar, but sensory loss was less pronounced than in the radicular pain patients. There was no significant difference between the two patient groups. Vibration detection was the most sensitive parameter with 73% abnormal values in radicular and 47% in pseudoradicular cases. These data verified the sensitivity of QST to detect sensory loss in radicular compression syndromes, and support a neuropathic component in low-back pain with radiculopathy. In contrast to some central pain syndromes this sensory loss involved predominantly large fiber functions. The subclinical sensory loss in pseudoradicular cases suggests that these patients may also have a neuropathic component of their chronic pain. The spatial incongruence of pain and sensory loss in pseudoradicular pain, however, may also indicate that the two are not causally related.
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Affiliation(s)
- Rainer Freynhagen
- Department of Anesthesiology, Heinrich-Heine-University of Düsseldorf, Düsseldorf, Germany
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Late results of surgery for herniated lumbar disk as related to duration of preoperative symptoms and type of herniation. ACTA ACUST UNITED AC 2008; 70:398-401; discussion 401-2. [PMID: 18262618 DOI: 10.1016/j.surneu.2007.04.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2006] [Accepted: 04/29/2007] [Indexed: 11/22/2022]
Abstract
BACKGROUND Ten to 40% of patients who have undergone state-of-the-art surgery for HLD do not obtain relief of pain. The relationship among timing of surgery for HLD, type of herniation, and clinical outcome, questioned in the present study, has rarely been referred to as an individual medical factor. METHODS Sixty-three patients belonging to a single ethnic group were called in 2 to 5 years after surgery and scored for change in severity of HLD-related pain (VAS) and current disability as scored by a functional rating system (Spangfort). RESULTS Patients with noncontained herniation (group 1), as compared with those with contained herniation (group 2), had had more intense radicular pain preoperatively (mean VAS, 8.3 vs 6.5), had a shorter history of pain (mean, 7.4 vs 15.8 weeks), and enjoyed a better functional outcome (good or fair in 96.4% vs 74.3%). Those in group 1 with a preoperative pain history of 6 weeks or less showed a greater decrease in pain intensity than those with a pain history of 6 to 12 weeks. Group 2 patients had had a longer preoperative history of symptoms than any in group 1 (>12 weeks in all) and showed an intermediate decrease in pain intensity. CONCLUSIONS Patients with noncontained herniation who do not show signs of improvement should be offered elective surgery after 6 to 8 weeks of observation; those having contained herniation should be advised that a certain degree of benefit can be expected from surgery, however late.
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Kobayashi S, Uchida K, Yayama T, Takeno K, Miyazaki T, Shimada S, Kubota M, Nomura E, Meir A, Baba H. Motor neuron involvement in experimental lumbar nerve root compression: a light and electron microscopic study. Spine (Phila Pa 1976) 2007; 32:627-34. [PMID: 17413466 DOI: 10.1097/01.brs.0000257559.84494.15] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN The aim of this study is to investigate changes in lumbar motor neurons induced by mechanical nerve root compression using an in vivo model. This study is to investigate the changes of lumbar motor neuron induced by mechanical nerve root compression using in vivo model. OBJECTIVES The effect of axonal flow disturbance induced by nerve root compression was determined in lumbar motor neuron. SUMMARY OF BACKGROUND DATA The lumbar motor neuron should not be overlooked when considering the mechanism of weakness, so it is important to understand the morphologic and functional changes that occur in motor neurons of the spinal cord as a result of nerve root compression. However, few studies have looked at changes of neurons within the caused by disturbance of axonal flow, the axon reaction, chromatolysis, and cell death as a result of mechanical compression of the ventral root. METHODS In mongrel dogs, the seventh lumbar nerve root was compressed for 1 week, or 3 weeks using a clip. Morphologic changes of the motor neurons secondary to the axon reaction were examined by light and electron microscopy. RESULTS Light and electron microscopy showed central chromatolysis of motor neurons in the lumbar cord from 1 week after the start of compression. After 3 weeks, some neurons undergoing apoptosis were seen in the ventral horn. CONCLUSION It is important to be aware that, in patients with nerve root compression due to lumbar disc herniation or lumbar canal stenosis, dysfunction is not confined to degeneration at the site of compression but also extends to the motor neurons within the lumbar cord as a result of the axon reaction. Patients with weakness of lower leg should therefore be fully informed of the fact that these symptoms will not resolve immediately after surgery.
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Affiliation(s)
- Shigeru Kobayashi
- Department of Orthopedic Surgery and Rehabilitation Medicine, Fukui University School of Medicine, Fukui, Japan.
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Jancalek R, Dubovy P. An experimental animal model of spinal root compression syndrome: an analysis of morphological changes of myelinated axons during compression radiculopathy and after decompression. Exp Brain Res 2006; 179:111-9. [PMID: 17103209 DOI: 10.1007/s00221-006-0771-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2006] [Accepted: 10/18/2006] [Indexed: 10/23/2022]
Abstract
The treatment of radicular pain is mainly empirical because there are only few experimental studies dealing with morphological changes during compression radiculopathy. The goal of the study was to investigate changes in the morphology of myelinated axons during spinal root compression and the influence of decompression in a new rat model. The number of myelinated axons and their diameter were measured at 1, 2, 5, and 8 weeks during compression of the dorsal spinal root. The same approach was applied for 1-week compression followed by decompression for 1 or 2 weeks and compression for 5 weeks followed by 3-week decompression. A decrease in the number of myelinated axons (particularly those of large diameters) occurred after compression for 1 week. Continued compression for up to 8 weeks resulted in centripetal increase in the number of myelinated axons and the persistence of a small fraction of large myelinated axons at the site of compression. After that time, a decreased number of axons and a reduced fraction of large myelinated axons occurred again. Decompression after 1-week compression caused a rapid increase in the number of both small and large myelinated axons within the spinal root including the site of compression. A small fraction of regenerated axons was found after 5-week compression followed by 3-week decompression. Finally, we investigated the time course of the temporary increase in the number of regenerated myelinated axons during dorsal root compression for up to 8 weeks. The efficacy of decompression was superior when applied one week after compression or after regress of the acute phase of aseptic inflammation associated with fragility of spinal root. The results of the study verify the need for early surgical decompression to prevent irreversible damage of the spinal roots.
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Affiliation(s)
- R Jancalek
- Department of Neurosurgery, St. Anne's University Hospital, 65691 Brno, Czech Republic.
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Quante M, Hauck M, Gromoll M, Hille E, Lorenz J. Dermatomal laser-evoked potentials: a diagnostic approach to the dorsal root. Norm data in healthy volunteers and changes in patients with radiculopathy. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2006; 16:943-52. [PMID: 17103230 PMCID: PMC2219653 DOI: 10.1007/s00586-006-0253-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2006] [Revised: 09/06/2006] [Accepted: 10/21/2006] [Indexed: 10/23/2022]
Abstract
We conducted a cross-sectional study of 40 radiculopathy patients in comparison with norm data from healthy subjects using a new electrophysiological method. Early manifestations of dorsal root impairment escape objective diagnosis by conventional somatosensory-evoked potentials due to the overlapping innervation of the affected dermatome by thickly myelinated mechanoreceptive afferents projecting to adjacent intact roots. Evidence suggested less intersegmental overlap for thermonociceptive afferents rendering laser-evoked potentials (LEP) sensitive to monosegmental dorsal root damage. Therefore we used this new method to study acute manifestations of monosegmental dorsal root pathology. Dorsal root function was tested in 12 healthy subjects and 40 sciatica patients by intraindividual interside comparison. Mechanosensibility and thermosensibility were clinically investigated. LEP were induced by moderately painful laser stimuli. The LEP were evaluated by amplitude and latency of the averaged electroencephalogram. Normal interside differences of LEP for amplitude were +/-22% (lower limb) and +/-35% (upper limb) and +/-15 to +/-16% for latency. Twenty-six patients (65%) showed significant LEP changes, mainly amplitude decreases. Six of these patients exhibited latency prolongations. Clinical testing yielded more frequent pathological results for pain compared to mechanosensibility. The study confirmed our preliminary evidence of LEP sensitivity to objectively document dorsal root impairment in patients suffering from acute monosegmental radiculopathy. This result opens the perspective of electrophysiologically differentiating the presence or absence of dorsal root pathology in patients with similar clinical symptoms but possibly different prognoses, which require different therapies.
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Affiliation(s)
- Markus Quante
- Department of Orthopaedics and Rheumatology, University Hospital Giessen and Marburg, Marburg, Germany.
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Abstract
Stable claudication has traditionally been treated conservatively by many clinicians as operative therapies involve considerable risk for a condition that is often slowly progressive and non-fatal. The relative safety of less invasive endovascular techniques brings potential survival benefits from the increased exercise tolerance that result. We aimed to revisit and clarify the aetiologies of intermittent claudication in a review of the rarer causes that can mimic atherosclerotic occlusive disease. An extensive search of Medline, Embase and the Cochrane databases was carried out to compile published work addressing the aetiology of claudication and specific non-atherosclerotic causes. The reference lists of these manuscripts were also searched for relevant articles. There are several vasculogenic and neurogenic causes for intermittent claudication, many of which are unrelated to atherosclerosis. Recognition of these rarer syndromes is essential when planning endovascular or operative management strategies. Consideration of non-atherosclerotic differential diagnoses is recommended when assessing the patient with intermittent claudication. This is particularly critical in the young patient whose pattern of symptoms and risk factors may not fit precisely with atherosclerosis.
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Affiliation(s)
- Ramon L Varcoe
- The Department of Surgery, The Sutherland Hospital, Kingsway, Caringbah, NSW, Australia
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Babbage CS, Coppieters MW, McGowan CM. Strain and excursion of the sciatic nerve in the dog: biomechanical considerations in the development of a clinical test for increased neural mechanosensitivity. Vet J 2006; 174:330-6. [PMID: 16914331 DOI: 10.1016/j.tvjl.2006.07.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2006] [Revised: 05/17/2006] [Accepted: 07/03/2006] [Indexed: 12/14/2022]
Abstract
Analysis of human nerve biomechanics has contributed to the validation of clinical tests to diagnose back pain of neural origin. Equivalent clinical tests for dogs would be valuable to differentially diagnose lumbosacral pain. To develop such a test, the increase in strain in the sciatic nerve of dogs and the longitudinal excursion of the nerve in relation to its surrounding structures during hind limb movements were evaluated. A miniature strain gauge was inserted into the sciatic nerve in seven canine cadavers and excursion was measured using a digital calliper. A cumulative increase in strain of 7.2% (+/-2.8%) was observed for the combined movements of hip flexion, stifle extension, hock flexion and digit extension (P<0.0001). Although all components contributed significantly to the increase (P=0.03), the sciatic nerve demonstrated a curvilinear response to increased loading. A 10.0+/-1.0mm excursion was recorded with stifle extension (P=0.002). It was concluded that, the sciatic nerve in dogs accommodates to joint movements by stretching and gliding. This biomechanical analysis has contributed to the development of a clinical test equivalent to the human straight leg raise to evaluate increased mechanosensitivity of the lumbosacral plexus.
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Affiliation(s)
- Christine S Babbage
- School of Animal Studies , The University of Queensland, Gatton Campus, QLD 4343 Gatton, Australia
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Sakamoto Y, Nakamura T, Takagi K. Functional and morphological changes of lumbar nerve roots induced by mechanical compression or the nucleus pulposus in contact with the root: analysis of fiber size-dependent vulnerability in rabbits. J Orthop Sci 2005; 9:598-604. [PMID: 16228678 DOI: 10.1007/s00776-004-0837-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2003] [Accepted: 08/27/2004] [Indexed: 11/24/2022]
Abstract
The variation in symptoms of spinal nerve root damage may be caused by the difference of the size of damaged nerve fiber or difference between the mechanical influence and some chemical factors. We studied the relative vulnerability of small versus large myelinated fibers to a focal compression and/or an application of nucleus pulposus. We prepared the mechanical compression model by clipping the nerve root and the nucleus pulposus model by applying autologous nucleus pulposus on the nerve root in a rabbit and evaluated nerve root damage with respect to its fiber diameter. Nerve conduction velocity (NCV) of large myelinated nerve fiber was reduced significantly in every group compared with a sham operation group (sham) after 1 day in compression, but in the nucleus pulposus group (NP) the velocity was reduced significantly compared with sham only after 7 days. Histologic examination revealed that the number of damaged large fibers increased significantly in the compression group compared with sham after 3 days, but there was no difference in NP. NCV of small myelinated nerve fibers was reduced significantly in both the compression and NP groups compared with sham after 7 days. Histologic study showed the number of damaged small fibers increased significantly in the compression group compared with sham after 7 days. However, in the NP group the number of damaged fibers did not increase compared with sham. In conclusion, large myelinated nerve fiber was damaged earlier than small myelinated nerve fiber by compression, while nerve fiber damage caused by only the nucleus pulposus had no relation to nerve fiber size.
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Affiliation(s)
- Yoshihiro Sakamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kumamoto University, 1-1-1 Honjo, Kumamoto 860-8556, Japan
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Kobayashi S, Baba H, Uchida K, Kokubo Y, Kubota C, Yamada S, Suzuki Y, Yoshizawa H. Effect of mechanical compression on the lumbar nerve root: localization and changes of intraradicular inflammatory cytokines, nitric oxide, and cyclooxygenase. Spine (Phila Pa 1976) 2005; 30:1699-705. [PMID: 16094269 DOI: 10.1097/01.brs.0000171910.97937.0e] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Investigation of intraradicular inflammation induced by mechanical compression. OBJECTIVE To investigate the mechanism of nerve root pain, this study used a lumbar nerve root compression model. SUMMARY OF BACKGROUND DATA The manifestation of pain at sites of inflammation has a close relationship with the release of mediators from macrophages. However, the mediators involved in inflammation of nerve roots as a result of mechanical compression remain almost unknown. METHODS In this study, the seventh lumbar nerve root of dogs was compressed with a clip for 3 weeks to observe the changes caused by compression. Immunohistochemistry was performed using the avidin-biotin-peroxidase complex method to observe the changes of T cells (CD45) and macrophages (Mac-1) after compression. Antibodies against as interleukin-1 (IL-1), tumor necrosis factor-alpha (TNF-alpha), inducible nitric oxide synthase (i-NOS), and cyclooxygenase (COX)-1 and 2 were used to examine the localization and changes of these mediators caused by nerve root compression. RESULTS In control animals, resident T cells were detected, but there were no macrophages. IL-1beta and COX-2 were positive in the Schwann cells and vascular endothelial cells, while COX-1 was detected in the vascular endothelial cells. However, no cells showed TNF-alpha or i-NOS positively. After nerve root compression, numerous T cells and macrophages appeared among the demyelinized nerve fibers. The macrophages were positive for IL-1beta, TNF-alpha, i-NOS, and COX-2. CONCLUSION Inflammatory cytokines, NO, and COX-2 may be deeply involved in radiculitis caused by mechanical compression, and these mediators seem to be important in the manifestation of root pain.
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Affiliation(s)
- Shigeru Kobayashi
- Department of Orthopaedics and Rehabilitation Medicine, Fukui University School of Medicine, Matsuoka, Fukui, Japan.
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Kobayashi S, Baba H, Uchida K, Shimada S, Negoro K, Takeno K, Yayama T, Yamada S, Yoshizawa H. Localization and changes of intraneural inflammatory cytokines and inducible-nitric oxide induced by mechanical compression. J Orthop Res 2005; 23:771-8. [PMID: 16022989 DOI: 10.1016/j.orthres.2005.01.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2005] [Indexed: 02/04/2023]
Abstract
STUDY DESIGN Investigation of intraneural inflammation induced by mechanical compression. OBJECTIVES In order to investigate the mechanism of neuropathy, this study used a median nerve compression model in dogs. Immunohistochemistry was used to examine the localization and changes of inflammatory cytokines and nitric oxide (NO). SUMMARY OF BACKGROUND DATA The manifestation of pain at sites of inflammation has a close relationship with the release of mediators from macrophages such as interleulin-1 (IL-1) and tumor necrosis factor-alpha (TNF-alpha), as well as with NO. However, the mediators involved in inflammation of nerve due to mechanical compression remain almost unknown. METHODS In this study, the median nerve of dogs was compressed with a clip for three weeks to observe the changes caused by compression. Immunohistochemistry was done by the avidin-biotin-peroxidase complex method to observe the changes of T cells (CD45) and macrophages (Mac-1) after compression. Antibodies against IL-1beta, TNF-alpha, and inducible nitric oxide synthesis (i-NOS) were used to examine the localization and changes of these mediators caused by nerve compression. RESULTS In control animals, resident T cells were detected, but there were no macrophages. IL-1beta was positive in the Schwann cells and vascular endothelial cells. However, no cells showed TNF-alpha or i-NOS positively. After nerve compression, numerous T cells and macrophages appeared among the demyelinized nerve fibers. The macrophages were positive for IL-1beta, TNF-alpha and i-NOS. CONCLUSION Inflammatory cytokines and NO may be involved in intraneural inflammatory changes arising from mechanical compression. Such mediators may be of importance in the manifestation of neuropathy.
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Affiliation(s)
- Shigeru Kobayashi
- Department of Orthopaedics and Rehabilitation Medicine, School of Medicine, Fukui Medical University, Shimoaizuki 23, Matsuoka, Fukui 910-1193, Japan.
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