Objectives: To establish the side incidence of acute lumbar disc prolapse and to determine whether there is a correlation between the side of the prolapse and hand dominance. Design: A retrospective study of consecutive cases of acute lumbar disc prolapse in which the diagnosis was confirmed at operation and the patients contacted about hand dominance. Summary of background data: The side incidence of operatively confirmed disc herniation does not appear to have been reported. Lifting and turning with the trunk in the flexed position is the commonest cause of an acute disc prolapse. Flexion and rotation of the lumbar spine, under load, may also give rise to unilateral fractures in the lumbar spine in fast bowlers in cricket and in eighty percent of these cases the fracture occurs on the opposite side to the bowling arm (ref . 1. ) Given that the majority of the population (eighty nine percent) are right handed it was speculated that the incidence of lumbar disc prolapse might not be equal and might be greater on the side opposite the dominant hand. Methods: From a review of case notes one hundred and twenty six patients were identified in which a sequestrated disc fragment was confirmed at operation. The side of the prolapse was noted. These patients were contacted to determine their hand dominance. Results: Fifty nine patients (47%) had a disc prolapse on the right side and sixty seven (55%) had a disc prolapse on the left side. There was no statistically significant difference in the numbers. Ninety two of the one hundred and twenty six patients contacted about their hand dominance responded: eighty three patients (90.2%) were right handed, eight (8.7%) were left handed and one patient (1.1%) was ambidextrous. Of the eighty three right handed patients, forty (48.2%) had a left sided disc prolapse and forty three (51.8%) had a right sided disc prolapse. Conclusion: This study revealed no difference in the side incidence of lumbar disc prolapse. There was no correlation either with the side of the prolapse and hand dominance. The findings are considered to support the view that a disc prolapse, and the side on which it occurs, is not a consequence of a single unilateral action but an end product of pre-existing disc degeneration in a midline structure

To identify the validity of the Straight leg raise and crossed straight leg raise in the diagnosis of Lumbar disc prolapse. Systematic review of the literature. The Medline database was used (1966-09) using the search terms Lumbar disc prolapse /disc herniation/straight leg raise /crossed straight leg raise. 80 papers were identified from the search after duplicates had been removed. Of these, 6 abstracts were read and the full papers of 5 reviewed. Four papers scored highly on the STARD criteria and were used in the final review. Two systematic reviews (Vroomen et al, 1999; Deville et al, 2000) and two diagnostic studies (Majessi et al,2000; Vroomen et al, 2002). The review by Vroomen in 1999 identified 37 papers. Trials were included that used CT myelography, MRI or surgical findings as the gold standard. Deville identified 15 studies with the gold standard being findings at surgery. The diagnostic trial by Majessi et al (2008) and Vroomen et al (2002) both used MRI as the gold standard. The Diagnostic odds ratio for SLR ranged from 2.3-8.8 and for CSLR from 4.4 to 11.2. The most valid clinical test in the diagnosis of Lumbar disc prolapse is. the crossed straight leg raise. The straight leg raise has not been shown to have high validity

Study design: A prospective comparison of MRI findings with surgical findings in patients presenting to our spinal triage service with a prospective diagnosis of a lumbar disc herniation. Objective: To investigate consistency between Radiologists’ interpretation of MRI scans, and comparison between MRI and surgical findings, in an attempt to identify those patients suitable for percutaneous treatment. Background: MRI has assumed a pre-eminent position in the diagnosis of lumbar disc prolapse. Methods: 87 consecutive patients presenting with signs and symptoms suggestive of a lumbar disc prolapse that underwent an MRI and based on that a discectomy. Results Reliability tests show only fair agreement (k=0.36) between the Radiologists and at best only moderate agreement (=0.41) between the Radiologists and surgical findings. Conclusion: MRI is an excellent tool for diagnosis of a disc prolapse. MRI is poor at defining the character of a disc prolapse, and does not appear to help in classifying discs suitable for percutaneous treatment

Study Purpose. To examine the presence of radicular pain and its relationship to the degree of lumbar nerve root compression in patients with a degenerative lumbar spine condition about to undergo surgery for either lumbar disc prolapse or lumbar canal stenosis. Background. The pathophysiology underlying radicular pain is not completely understood but it is thought that nerve root compression is a key factor and from a surgical perspective, decompressing the nerve root is considered to be the key therapeutic step. However, despite often severe root compression in patients with lumbar stenosis, radicular pain is not a typical feature. Methods. Thirty-nine pre-surgical patients with either lumbar disc prolapse or lumbar canal stenosis were studied using the Standardised Evaluation of Pain (StEP), a clinical assessment tool known to predict with a high degree of sensitivity and specificity the presence or absence of lumbar radicular pain. A nerve root compression score was given from lumbar MRI for each patient by a neuroradiologist blinded to the patients history. Results. The StEP assessment tool was able to distinguish the presence or absence of radicular pain with high sensitivity and specificity. This correlated well with the pre-operative diagnosis of disc prolapse or canal stenosis. The relationship between radicular pain and nerve root compression was less clear and will be discussed. Conclusion. This study confirms StEP as a useful bedside tool for identifying the presence of radicular pain in patients with a degenerative lumbar spine condition. Nerve root compression per se does not necessarily produce radicular pain. Conflicts of Interest. None. Source of Funding. None. This study has not been published or presented at a previous meeting

Study design: A prospective comparison of MRI findings with surgical findings in patients presenting to our spinal triage service with a prospective diagnosis of a lumbar disc herniation. Objective: To investigate consistency between radiologists interpretation of MRI scans, and comparison between MRI and surgical findings, in an attempt to identify those patients suitable for percutaneous treatment. Background: MRI has assumed a preeminent position in the diagnosis of lumbar disc prolapse. Methods: 87 consecutive patients presenting with signs and symptoms suggestive of a lumbar disc prolapse that underwent an MRI and based on that a discectomy. Results: Reliability tests show only fair agreement (k=0.36) between the radiologists and at best only moderate agreement (k=0.41) between the radiologists and surgical findings. Conclusions: MRI is an excellent tool for diagnosis of a disc prolapse but does not appear to help in classifying discs suitable for percutaneous treatment

Aim: The aim is to assess the accuracy of post-contrast imaging in identifying recurrent disc prolapse (RDP). Material and methods: 246 revision discectomies performed between January 1994 and June 2004 were considered. Of these, for 192 LIRDs, post-contrast scans (95 CTs and 97 MRIs) within 6 months of operation, and adequate operation records were available. Original scan reports and scan interpretation of an independent observer were taken into account. Results: Of 95 post-contrast CTs, 88 showed RDP (29 large-contained, 12 large-sequestrated, 39 moderate-contained, and 8 small-contained), 2 hypertrophic epidural scar (HES), and 5 lateral recess stenosis but no RDP or HES. From operation records, 30 of these 88 were found to have HES, but no RDP. Also, operation records confirmed presence of RDP in 21 of 29 large-contained (72.4%), 10 of 12 large-sequestrated (83.3%), 16 of 39 moderate-contained (41%) and 2 of 8 small-contained (25%). Of the 5 which did not show RDP, 2 (40%) were found to have RDP (1 moderate-contained and 1 large-contained) during operation. Of 97 post-contrast MRIs, 85 showed RDP (18 large-contained, 22 large-sequestrated, 26 moderate-contained,4 moderate-sequestrated,13 small-contained, and 2 small-sequestrated), 5 HES, and 7 lateral recess stenosis but no RDP or HES. From operation records, 31 of these 85 were found to have HES, but no RDP. Also, operation records confirmed presence of RDP in 10 of 18 large-contained (55.6%), 19 of 22 large-sequestrated (86.4%), 8 of 26 moderate-contained (30.8%), 4 of 4 moderate-sequestrated (100%), 6 of 13 small-contained (46.2%) and 1 of 2 small-sequestrated (50%). Of the 7 which did not show RDP, 1 (14.3%) was found to have moderate-contained RDP during operation. Conclusion: Accuracy of post-contrast scans is proportional to the size of RDP. MRI has high accuracy for sequestrated RDP

Study design: Prospective longitudinal cohort study with three month and one year follow up.

Objective: To determine what factors influence standard spine and urinary outcome measures at 3 months in cauda equine syndrome with particular attention being given to timing of onset of symptoms and timing of surgery.

Subjects: There were 31 cases submitted from the membership of BASS who underwent urgent surgery for cauda equina syndrome. Three month follow up was achieved in 25 (80%).

Outcome measures: Oswestry disability index (ODI), Visual analogue score for leg pain, Visual analogue score for back pain and incontinence questionnaire using a short form MRC outcome tool.

Results: The average age was 43 years. Ten patients had surgery within 48 hours of onset of symptoms, the remainder had more than 48 hours to surgery. Most patients received prompt attention after reaching secondary care with only four waiting more than 24 hours for surgery after scanning. There was no difference in ODI. VAS leg and back were better in the less than 48 hours group. Urinary symptoms and satisfaction did not appear to be influenced by surgery within 48 hours.

Conclusion: The duration of symptoms prior to surgery does not appear to influence the short-term outcome as measured by the Oswestry Disability Index and specific questions related to satisfaction with urinary outcome measures.

The purpose of this study was to design a questionnaire to evaluate patients’ satisfaction with the healthcare system relating to their spinal procedure, and to gather information relating to pre and post operative management. If successful, this questionnaire will be incorporated into the FASTER (Function after spinal treatment, exercise and rehabilitation) study, with the aim of identifying common care pathways and to understand where stumbling blocks arise.

The questionnaire included three sections: Care before surgery, care after surgery, plus general measures of satisfaction. Patients were randomly selected from the hospital records if they had undergone a lumbar discectomy or lateral nerve root decompression within the past year; this included both NHS and private patients.

34 pilot questionnaires were sent, to date 18 have been returned (9 NHS and 9 private patients). It was found that 79% of patients went to their GP when first experiencing pain/discomfort; however, alarmingly, an overwhelming majority of these patients felt their problem was not dealt with correctly at this stage. Fifty percent of the patients who went through the NHS “Definitely” felt left alone to deal with their problem. Only 10% of patients had physiotherapy prior to surgery and none went to pain management classes. 32% of patients received physiotherapy after leaving hospital; however, in all but one case this was after returning with symptoms.

Despite this, patients in general were very pleased with the care they received during there hospital stay. This pilot data provides an insight into the issues experienced by spinal surgery patients.

Purpose of study and background

The primary aim of the study was to test the feasibility of conducting a full RCT with economic analysis and help to inform the provision of physiotherapy in a specific sub-group of patients with sciatica

Study Design: Review of patients with massive disc prolapse, with a minimum of 50% canal occlusion, treated non-operatively. Objectives: To demonstrate the behaviour of massive disc prolapse treated non-operatively. Subjects: Patients with massive disc prolapse whose symptoms had started to resolve or who had refused surgery. Outcome Measures: Spontaneous reduction of disc herniation on MRI scans. Results: There were 10 patients who have had massive lumbar disc prolapse treated non-operatively. All had MRI scans which showed a lumbar disc prolapse occluding greater than 50% of the canal diameter on the axial cuts. The average occlusion of the canal was 62%. Repeat MRI scans showed reduction of the disc prolapse in all cases, with an average of 83% (range 68–100) reduction in the canal occlusion. The scans were performed between 6 and 68 months apart. 9/10 patients had resolution of leg pain. One patient had persistent leg pain despite complete resolution of the disc prolapse. He went on to have an exploration of the right S1 nerve root. No disc prolapse was identified and the S1 root was free and healthy. This however resolved the majority of his leg pain. Conclusion: We have demonstrated that the natural history, in these cases of massive prolapse was to resolve both clinically and radiologically in the majority of cases

Background. Gore and Nadkarni described a ‘Gore sign’ of reproducing radiating leg pain by palpation of distal nerve root endings in the foot for L5 and S1 nerve roots in lumbar radiculopathy due to disc prolapse. Purpose. This sign was explored and observation of symptoms recorded. Results. There were 31 patients, 20 females and 11 males, aged 25 to 76 years. 13 patients had acute disc prolapse, 14 had lumbar canal stenosis, 3 had annular tears and one had a facet cyst. Radiating leg pain was reproduced in all patients by palpation of distal nerve root endings and was immediately relieved by local anaesthetic injection around distal nerve root endings in all patients (second part of Gore test). New clinical signs were observed which have not been described before:. Back pain was reproduced in 21 patients. L4 nerve root pain was reproduced in 13 patients by palpation of the proximal tibia. Crossed leg pain was reproduced in 5 patients. Reproduction of pain by palpation of more than one distal nerve root ending was observed in 16 patients. Cessation of radiating leg pain by palpation of distal nerve root endings in two patients. These test were positive in patients with varied pathology producing radiculopathy, not just disc prolapse. Conclusion. Provocative nerve root tension signs can be difficult in severe pain. The tests described above can be performed without having to move the patient's lower limb. These observations open up discussion on the mechanism of radiculopathy and new ways of treatment. Conflicts of interest: None. Sources of funding: None

Background. Acute lumbar radiculopathy is a very painful condition sometimes requiring admission for strong analgesia. Purpose. To evaluate the efficacy of distal nerve root blocks as an outpatient procedure for immediate pain relief. Methods. Local anaesthetic was injected in the distal nerve root areas of the leg and foot in the clinic in patients with lumbar radiculopathy who consented to the procedure. Results. There were 29 patients, 18 females and 11 males, aged 25 to 76 years. 13 patients had acute lumbar disc prolapse, 11 had lumbar canal stenosis, 2 had annular tears and one a facet joint cyst. The VAS pain scores ranged from 3 to 11 (patient's description), with an average VAS score of 7.5. The improvement in VAS scores was between 2 and 9 with average improvement of 6. 19 patients had associated back pain which improved in 14. Walking improved in all 29 patients. Pain relief was immediate in all patients. This lasted from 30 min to 11 days with one patient having no recurrence. 27 patients had at least 24 hours pain relief. All patients could be sent home immediately after the procedure. 12 patients had recent onset of foot weakness which improved one MRC grade immediately after the injection. The analgesic effect was most significant in acute disc prolapse. There were no complications. Conclusion. This technique is simple and would be valuable in the acute setting to provide immediate pain relief allowing immediate discharge from accident and emergency. Conflicts of interest: None. Sources of funding: None

The December 2014 Spine Roundup. 360 . looks at: surgeon outcomes;. complications and scoliosis surgery; is sequestrectomy enough in lumbar disc prolapse?; predicting outcomes in lumbar disc herniation; sympathectomy has a direct effect on the dorsal root ganglion; and distal extensions of fusion in adolescent idiopathic scoliosis

To determine the clinical efficacy of vitamin-D supplementation on pain intensity and functional disability in patients with chronic lower back pain. This prospective cohort study was conducted from 20th March 2017 to 19th March 2019. The inclusion criteria were patients of CLBP aged between 15 to 55 years. Exclusion criteria included all the patients with Disc prolapse, Spinal stenosis, Any signs of neurological involvement, Metabolic bone disease (Hypo- or Hyperparathyroidism) and Chronic kidney disease/Chronic liver disease. Patients were supplemented with 50,000 IU of oral vitamin-D3 every week for 8 weeks (induction phase) and 50,000 IU of oral vitamin-D3 once monthly for 6 months (maintenance phase). Efficacy parameters included pain intensity and functional disability measured by VAS and modified Oswestry disability questionnaire (MODQ) scores at baseline, 2, 3 and 6 months post-supplementation. Vitamin-D3 levels were measured at baseline,2,3 and 6 months. A total of 600 patients were included in the study. The mean age of patients was 44.2 ± 11.92 years. There were 337 (56.2%) male patients while 263 (43.8%) female patients. Baseline mean vitamin-D levels were 13.32 ± 6.10 ng/mL and increased to 37.18 ± 11.72 post supplementation (P < 0.0001). There was a significant decrease in the pain score after 2nd, 3rd& 6th months (61.7 ± 4.8, 45.2 ± 4.6 & 36.9 ± 7.9, respectively) than 81.2 ± 2.4 before supplementation (P < 0.001). The modified Oswestry disability score also showed significant improvement after 2nd, 3rd & 6th months (35.5, 30.2 & 25.8, respectively) as compared to baseline 46.4 (P < 0.001). About 418 (69.7%) patients attained normal levels after 6 months. Vitamin-D supplementation in chronic lower back pain patients may lead to improvement in pain intensity and functional ability

The use of nerve root blocks is common in the management of radicular pain due to lumbar disc prolapse. However, most papers reporting their use do not necessarily specify the position or level at which the needle is positioned with respect to the level of pathology. We therefore set out to investigate this. We performed a survey of medical practitioners across the UK with an interest or involvement in the management of radicular pain secondary to lumbar disc prolapse The survey depicted the clinical scenario of a patient with radicular pain from an L4/5 disc prolapse and a number of questions were asked in relation to the use of nerve root blocks. Questionnaires were sent to 319 practitioners. We received 153 responses of which, 120 (37.6%) were sufficiently complete to be analysed. Of those who responded, 83% used a combination of local anaesthetic and steroids together with or without contrast. There were variations across the respondents in terms of the level injected with 22.5% injecting at the level of the L4/5 foramen, while 45% injected at the level of the L5/1 foramen. Differences were also noted when respondents were subgrouped according to their speciality. Of those who worked in pain management, 34.1% injected at the L4/5 foramen while 31.8% injected at the L5/1 foramen. For spine surgeons the respective figures were 20.5% and 43.2% and for radiologists 9.4% and 65.6%. In the treatment of radicular leg pain, there are apparent variations in the use and positioning of root blocks for a given level of disc pathology. This suggests that caution is necessary when considering the validity of published studies on the use of root blocks relative to an individual clinician's practice

Lumbar steroid injection can be endorsed as a treatment component for lumbrosacral radicular pain syndrome resulting from disc herniation. The facet joint steroid injection seems to be beneficial for patients with chronic backache due to the facet joint arthritis and in the lumbar Spondylosis. We did a retrospective review of 31 patients whom we treated between 2004 and 2005 with follow up of 6 months to 24 months. There were 19 females and 12 males, aged between 29–81 years. Five patients had previous surgery for simple discectomy to posterior spinal fusion. Four patients had multiple disc prolapse at 3–4 levels, 2 patients had a severe lumbar spondylosis and spinal stenosis. The remaining 20 patients had a single level disc prolapse. All these patients were given caudal and facet joint blocks. The pre and post steroid injection Oswestry score was done. After steroid injection the Oswestry score improved by 30%. Majority of the patients had pain relief for 2–18 months. The pain relief was much better in the non operative group with single level disc pro-lapse and those patients with lumbar spondylosis. In patients with chronic back pain there is an inflammatory basis for pain generation. Lumbar steroid injection seems to be beneficial in patients with disc prolapse and lumbar spondylosis. In the literature various randomized trials have been done and their results are controversial. Our study showed definitive improvement in terms of pain and function of our patient

Prospective Study Design. 198 consecutive patients with back pain leg pain with MRI scan showing disc prolapse were operated from June 2001 to January 2004. In 22 patients it was found that the cause of nerve root compression was a localised venous plexus and the disc was intact. Objectives: To emphasize the fact that the clinical presentation of a localised venous plexus of epidural veins in the lumbar spine can resemble that of an acute disc prolapse. Summary of Background data: After reporting 6 cases of this type in Spine Volume 28 Number 1 we designed a prospective study of all discetomies done in our institution. Our outcome suggests that the finding of enlarged epidural veins during lumbar spine disc decompression is relatively common, but it is only recently that they have been implicated as the cause of the presenting symptoms. Methods and Results: 198 patients presented with severe low back pain accompanied by sciatica, which had begun acutely. Physical examination in most of these patients showed the presence of neurological signs in the affected leg. The diagnosis of possible disc prolapse with nerve compression was demonstrated by MRI scan. However , at surgery, in 22 patients the intervertebral disc appeared to be relatively normal without any bulge and intact annulus, but a large venous structure in the form of plexus of epidural vein compressing the nerve root was found in the spinal canal.. The configuration of this venous plexus matched the MRI findings. The symptoms were relieved by decompression of the spinal canal and ablation of the veins. Conclusion: Lumbar spine venous plexi of epidural veins can cause nerve root compression and the MRI image of a localised plexus of epidural veins can closely resemble that of a prolapsed intervertebral disc. Could this be the cause of failed back syndrome in patients who have already undergone decompression and discetomy? Wenger et al show success rate of 92.5% to 94.7% after discetomy but still there is an failure rate of 7.5 to 5.3% leading to failed back syndrome. The incidence of symptomatic lumbar epidural varices is said to be low. Zimmerman et al quoted their incidence as 0.067% and Hanley et al 5%. Our study shows an incidence of 11.11%

Introduction: ACDF involves cancellation of the diseased spinal motion segment, the neighboring spinal segments take the burden of excessive compensatory spinal movements and strain resulting in early degeneration. Adjacent segment degeneration with new, symptomatic radiculopathy occurs after ACDF in 2–3% of patients per year on cumulative basis. An estimated 15% of patients ultimately require a secondary procedure at an adjacent level. An alternative to fusion is total disc arthroplasty (TDA). The key advantage of this promising technology is restoration and maintenance of normal physiological motion rather than elimination of motion. We describe 4 patients with a serious complication observed following implantation of the Bryan disc prosthesis in our cohort of 48 patients. Material and Results:. Patient #1: 43 M, with neck pain & left brachalgia, with left C6 dermatome signs, with MRI findings of C5/6 disc prolapse with left C6 root impingement, undergoing C5/6 Bryan TDA in April 2004, with treatment recommendation of C3/4 and C6/7 Bryan TDA in January 2006. Patient #2: 47 M, with worsening gait over 2 years with right brachalgia, with findings of progressive cervical myelopathy with right C5 radiculopathy, with MRI findings of severe C5/6 disc degeneration with spinal cord compression, undergoing C5/6 Bryan TDA in January 2003, with MRI FU findings after 16/12 with new left C6/7 disc prolapse and left C6 radiculopathy, with treatment recommendation of C6/7 Bryan TDA, on waiting list. Patient #3: 45 F, 6 years of neck pain with right brachialgia, with right C5 dermatome signs, with MRI findings of C5/6 central disc herniation with cord compression, undergoing C5/6 Bryan TDA in December 2000, with FU MRI showing after 5 years and 7/12 (67/12) new C6/7 canal narrowing with right C6 radiculopathy, and treatment recommendation of C6/7 Bryan TDA. Patient #4: 38 M, worsening gait over 5 years and exam findings of progressive cervical myelopathy, with MRI findings of severe C5/6 disc degeneration with spinal cord compression, undergoing C5/6 Bryan TDA in August 2003, with FU MRI showing after 3 years new C4/5 disc prolapse with C5 radiculopathy, followed by treatment recommendation of C4/5 Bryan TDA. Discussion & Conclusions: Bryan TDR did not prevent the development of accelerated ASD. Evidence from in vivo X ray studies suggested that the range of motion across the operated levels did not match the physiological ROM. Despite the MRI images preoperatively, it is difficult to exclude the natural progression of degeneration as a reason for ASD

Purpose:. To evaluate if adding clonidine to a standard nerve root block containing local anaesthetic and steroid improved the outcome of patients with severe lumbar nerve root pain secondary to MRI proven lumbar disc prolapse. Methods:. We undertook a single blind, prospective, randomised controlled trial evaluating 100 consecutive patients with nerve root pain secondary to lumbar disc prolapse undergoing trans-foraminal epidural steroid injection either with or without the addition of clonidine. 50 patients were allocated to each arm of the study. The primary outcome measure was the avoidance of a second procedure- repeat injection or micro-discectomy surgery. Secondary outcome measures were also studied: pain scores for leg and back pain using a visual analogue scale (VAS), the Roland Morris Disability Questionnaire (RMDQ) and the Measure Your Own Medical Outcome Profile (MYMOP). Follow up was carried out at 6 weeks, 6 months and 1 year. Results:. No serious complications occurred. Of the 50 patients who received the addition of clonidine, 56% were classified as successful injections, with no further intervention required, as opposed to 40% who received the standard injection. This difference did not reach statistical significance (p=0.109, chi-squared test). All secondary measures showed no statistically significant differences between the groups except curiously, the standard group who had been classified as successful had better leg pain relief than the clonidine group (p=0.026) at 1 year. Conclusions:. This pilot study has shown a 16% treatment effect with adding clonidine to lumbar nerve root blocks and that it is a safe injectate for this purpose