Ultrasonic appearance of rhabdomyolysis in patients with crush injury in the Wenchuan earthquake.
Su Bai-hai,Qiu Li,Fu Ping,Luo Yan,Tao Ye,Peng Yu-lan
Chinese medical journal
BACKGROUND:On May 12, 2008, a major earthquake hit Wenchuan County in Sichuan Province of China. The number of cases of crush injury following this event was high. Ultrasonic appearance of rhabdomyolysis (RM) caused by crush injury in the Wenchuan earthquake was observed to evaluate the diagnostic value of ultrasound for detection of rhabdomyolysis. METHODS:We analyzed clinical and ultrasonic manifestations of 50 cases of RM and 18 cases of RM with osteofascial compartment syndrome (OCS). All cases were caused by crush injury in the Wenchuan earthquake. For these RM patients, we also evaluated the correlations between creatine kinase (CK) and the scope of the muscle lesions as observed by ultrasound. RESULTS:There were differences in clinical symptoms, physical signs and ultrasonic appearance between the two groups of patients. The ultrasonic characteristics of the RM were as follows: the striated muscle in the lesions thickened with good overall continuity, and the muscle texture was vague; the strength of the echo was uneven and the echo was cloudy or ground glass-like. Liquid dark zones appeared between muscles and were spindle-like or irregular in shape. There were no blood flow signals in the liquid dark areas. The volume of the striated muscle increased in patients with OCS; the fascia wrapping the muscle showed arched protrusions and significant displacement. The flow velocity of the distal arteries decreased and the spectrum was abnormal. The muscle lesion scope of RM group and RM and OCS group was (7.8 +/- 2.0) cm and (13.6 +/- 3.1) cm, respectively. The correlation coefficient (r) between the muscle lesion scope and the CK was 0.681 for the RM group (P < 0.05) and 0.516 for the RM and OCS group (P < 0.05). CONCLUSIONS:The ultrasonogram of RM has characteristic manifestations and can provide important information for clinical diagnosis and treatment of rhabdomyolysis.
The anatomy of the lumbar intervertebral disc syndrome.
Bogduk N
The Medical journal of Australia
Four elements of the nervous system may be involved in the production of the lumbar intervertebral disc syndrome. These are the lumbosacral nerve roots, the spinal nerves, the dorsal rami and the sinuvertebral nerves. Each nerve is associated with a particular group of pathological conditions which may irritate the nerve and produce symptoms. The anatomy of each nerve determines which particular conditions may irritate it. Moreover, one or both of two mechanisms may be involved in symptom production. The type of nerve irritated determines which mechanism is involved. In the first mechanism, low back pain and referred lower limb symptoms are produced when afferent fibres from dorsal and ventral rami are stimulated where they pass in common through spinal nerves or nerve roots. In the second mechanism, dorsal rami or sinuvertebral nerves are stimulated. This directly produces low back pain, but referred pain is produced by reflex mechanisms in the spinal cord.
Tubular discectomy versus conventional microdiscectomy for the treatment of lumbar disc herniation: long-term results of a randomised controlled trial.
Overdevest Gijsbert M,Peul Wilco C,Brand Ronald,Koes Bart W,Bartels Ronald Hma,Tan Wee F,Arts Mark P,
Journal of neurology, neurosurgery, and psychiatry
BACKGROUND:The reference surgical procedure for the treatment of lumbar disc herniation is open microdiscectomy. Minimal invasive discectomy with tubular retractors is hypothesised to cause less tissue damage and result in lower blood loss, less postoperative pain and faster recovery. We previously reported our 1 and 2-year results, and found no better outcomes of tubular discectomy compared with open microdiscectomy. Until now, no studies on tubular discectomy have reported results with more than 2 years of follow-up. Studies with long-term follow-up are required to determine if clinical outcomes are sustained and to assess specific long-term outcomes such as reoperation rate and iatrogenic low back pain due to impaired spinal integrity. The aim of this study is to evaluate the 5-year results of tubular discectomy compared with conventional microdiscectomy. METHODS:The study was designed as a double-blind randomised controlled trial. 325 patients with a symptomatic lumbar disc herniation were randomly allocated to tubular discectomy (166 patients) or conventional microdiscectomy (159 patients). Repeated standardised follow-up measurements were performed at 2, 4, 6, 8, 12, 26, 38, 52, 78, 104, 156, 208 and 260 weeks after randomisation. Main outcomes are the Roland-Morris Disability Questionnaire for Sciatica (RDQ), Visual Analogue Scale for leg pain and low back pain, self-perceived recovery and reoperation incidence. RESULTS:There was no clinically significant difference between tubular discectomy and conventional microdiscectomy regarding the main clinical outcomes at any time point during the 5 years of follow-up. RDQ scores at 5 years were 4.3 (95% CI 3.3 to 5.2) in the tubular discectomy group and 3.4 (95% CI 2.4 to 4.5) in the conventional microdiscectomy group. The mean difference of 0.9 (95% CI -0.6 to 2.2) was not significant. Mean differences for leg pain and back pain were 0.2 (95% CI -5.5 to 6.0) and 0.4 (95% CI -5.9 to 6.7), respectively. 77% of patients allocated to conventional discectomy reported complete or near-complete recovery of symptoms compared with 74% of patients allocated to tubular discectomy (p=0.79). The reoperation rate was 18% in the tubular discectomy group and 13% in the conventional discectomy group (p=0.29). CONCLUSIONS:Long-term functional and clinical outcome did not differ between patients allocated to tubular discectomy and conventional microdiscectomy. Primary and secondary outcome measures did not support the hypothesised advantages of tubular discectomy over conventional microdiscectomy. TRIAL REGISTRATION NUMBER:ISRCTN51857546.
10.1136/jnnp-2016-315306
Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain.
van der Windt Daniëlle Awm,Simons Emmanuel,Riphagen Ingrid I,Ammendolia Carlo,Verhagen Arianne P,Laslett Mark,Devillé Walter,Deyo Rick A,Bouter Lex M,de Vet Henrica Cw,Aertgeerts Bert
The Cochrane database of systematic reviews
BACKGROUND:Low-back pain with leg pain (sciatica) may be caused by a herniated intervertebral disc exerting pressure on the nerve root. Most patients will respond to conservative treatment, but in carefully selected patients, surgical discectomy may provide faster relief of symptoms. Primary care clinicians use patient history and physical examination to evaluate the likelihood of disc herniation and select patients for further imaging and possible surgery. OBJECTIVES:(1) To assess the performance of tests performed during physical examination (alone or in combination) to identify radiculopathy due to lower lumbar disc herniation in patients with low-back pain and sciatica;(2) To assess the influence of sources of heterogeneity on diagnostic performance. SEARCH STRATEGY:We searched electronic databases for primary studies: PubMed (includes MEDLINE), EMBASE, and CINAHL, and (systematic) reviews: PubMed and Medion (all from earliest until 30 April 2008), and checked references of retrieved articles. SELECTION CRITERIA:We considered studies if they compared the results of tests performed during physical examination on patients with back pain with those of diagnostic imaging (MRI, CT, myelography) or findings at surgery. DATA COLLECTION AND ANALYSIS:Two review authors assessed the quality of each publication with the QUADAS tool, and extracted details on patient and study design characteristics, index tests and reference standard, and the diagnostic two-by-two table. We presented information on sensitivities and specificities with 95% confidence intervals (95% CI) for all aspects of physical examination. Pooled estimates of sensitivity and specificity were computed for subsets of studies showing sufficient clinical and statistical homogeneity. MAIN RESULTS:We included 16 cohort studies (median N = 126, range 71 to 2504) and three case control studies (38 to100 cases). Only one study was carried out in a primary care population. When used in isolation, diagnostic performance of most physical tests (scoliosis, paresis or muscle weakness, muscle wasting, impaired reflexes, sensory deficits) was poor. Some tests (forward flexion, hyper-extension test, and slump test) performed slightly better, but the number of studies was small. In the one primary care study, most tests showed higher specificity and lower sensitivity compared to other settings.Most studies assessed the Straight Leg Raising (SLR) test. In surgical populations, characterized by a high prevalence of disc herniation (58% to 98%), the SLR showed high sensitivity (pooled estimate 0.92, 95% CI: 0.87 to 0.95) with widely varying specificity (0.10 to 1.00, pooled estimate 0.28, 95% CI: 0.18 to 0.40). Results of studies using imaging showed more heterogeneity and poorer sensitivity. The crossed SLR showed high specificity (pooled estimate 0.90, 95% CI: 0.85 to 0.94) with consistently low sensitivity (pooled estimate 0.28, 95% CI: 0.22 to 0.35).Combining positive test results increased the specificity of physical tests, but few studies presented data on test combinations. AUTHORS' CONCLUSIONS:When used in isolation, current evidence indicates poor diagnostic performance of most physical tests used to identify lumbar disc herniation. However, most findings arise from surgical populations and may not apply to primary care or non-selected populations. Better performance may be obtained when tests are combined.
10.1002/14651858.CD007431.pub2
Sciatica: what the rheumatologist needs to know.
van Tulder Maurits,Peul Wilco,Koes Bart
Nature reviews. Rheumatology
Sciatica is a set of symptoms rather than a specific diagnosis, and is caused by a herniated lumbar disc in the vast majority of cases. The most important symptom is lower limb pain radiating below the knee and into the foot and toes. The clinical course of acute sciatica is generally favorable, with most pain and related disability improving within 2-4 weeks with or without treatment. Diagnosis mainly involves history taking and physical examination. Imaging is warranted if there is evidence of an underlying pathology other than disc herniation, such as infection or malignancy, and in patients with severe symptoms that do not improve after 6-8 weeks of conservative treatment. MRI is the preferred imaging modality, as it can visualize soft tissues better than CT and does not expose the patient to ionizing radiation. Conservative treatment is generally the first-line option in patients with sciatica; however, the currently available evidence does not show any intervention--including a broad range of conservative and surgical approaches--to have clearly superior outcomes. Thus, patient preference seems to be an important factor in the clinical management of sciatica.
10.1038/nrrheum.2010.3
Pathophysiology of low back pain during exposure to microgravity.
Sayson Jojo V,Hargens Alan R
Aviation, space, and environmental medicine
Astronauts exposed to microgravity frequently report low back pain. This pain is described as moderate to severe in intensity. This condition warrants investigation as low back pain may hinder an astronaut's ability to perform challenging tasks by virtue of disruption of sleep and, subsequently, mental concentration. It is reported by astronauts that a "fetal tuck position" described as knees to chest position relieves back pain. It is possible that the pathogenesis of back pain in microgravity is discogenic (or mechanical) and somatic, referred from the sinuvertebral nerves due to excessive expansion of the lumbar intervertebral discs associated with reduction of gravitational compressive loads in space. The fetal tuck position may increase lumbar intervertebral disc hydrostatic pressure by flexion and transfer of spinal compressive forces toward the anterior region of the lumbar discs, subsequently reducing disc volume. Moreover, this position may reduce Type IV mechanoreceptor facilitation and nerve impulse propagation from the sinuvertebral nerves of the annulus fibrosus, and thus diminish low back pain perception. Elongated posterior soft tissues (apophyseal joint capsules and ligaments) with spinal flexion may potentially stimulate Type I and II mechanoreceptors. This neutralizes substance P in the spinal cord dorsal horn by increasing naturally occurring opioids such as enkephalins. Separately, other investigators have reported a higher incidence of herniated discs (HNP) in astronauts postflight. Further studies of countermeasures are recommended to prevent excessive spinal elongation and disc expansion, reduce low back pain in microgravity, and simulate 1-G disc homeostasis, which may also help prevent HNPs postflight.
10.3357/asem.1994.2008
Comparison of simple discectomy and instrumented posterior lumbar interbody fusion for treatment of lumbar disc herniation combined with Modic endplate changes.
Cao Peng,Chen Zhe,Zheng Yuehuan,Wang Yuren,Jiang Leisheng,Yang Yaoqi,Zhuang Chengyu,Liang Yu,Zheng Tao,Gong Yaocheng,Zhang Xingkai,Wu Wenjian,Qiu Shijing
Chinese medical journal
BACKGROUND:The purpose of this retrospective study was to compare the surgical outcomes of simple discectomy and instrumented posterior lumbar interbody fusion (iPLIF) in patients with lumbar disc herniation and Modic endplate changes. Our hypothesis was that iPLIF could provide better outcome for patients with refractory lumbar disc herniation and Modic changes (LDH-MC). METHODS:Ninety-one patients with single-segment LDH-MC were recruited. All patients experienced low back pain as well as radicular leg pain, and low back pain was more severe than leg pain. Forty-seven patients were treated with discectomy and 44 were treated with iPLIF. The outcomes of both low back pain and radicular leg pain using visual analogue scale (VAS) as well as the clinical outcome related to low back pain using Japanese Orthopaedic Association (JOA) score were assessed before and 18 months after surgery, respectively. RESULTS:Both low back and leg pain were significantly improved 18 months after simple discectomy and iPLIF. Compared to patients undergoing simple discectomy, low back pain was significantly reduced in patients undergoing iPLIF, but there was no significant difference in leg pain between two groups. Solid fusion was achieved in all patients who underwent iPLIF. CONCLUSIONS:In patients with LDH-MC, iPLIF can yield significantly superior outcome on the relief of low back pain compared to simple discectomy. Simple discectomy can relieve radicular leg pain as efficient as iPLIF. Accordingly, iPLIF seems to be a reliable treatment for patients with LDH-MC and predominant low back pain.
Lumbar disc arthroplasty.
Gamradt Seth C,Wang Jeffrey C
The spine journal : official journal of the North American Spine Society
BACKGROUND CONTEXT:Painful lumbar disc degeneration is one of the most common ailments treated by spine surgeons. Currently, early disc disease and herniation are often treated with microdiscectomy. Late disc degeneration is usually treated with arthrodesis. With the advent of new technology and techniques in lumbar disc arthroplasty, interest in preserving spinal motion at degenerated motion segments has increased. The goals of lumbar disc arthroplasty are to provide long-term pain relief at the degenerated disc level, to restore disc height to protect neural elements and to preserve motion to prevent posterior facet arthropathy and adjacent segment disease. PURPOSE:The purpose of this review is to examine the anatomy and biomechanics of the lumbar motion segment to determine the features that successful disc arthroplasty prosthesis must possess. In addition, the early clinical results of three prostheses currently being used in humans are reviewed. STUDY DESIGN/SETTING:Review of the literature. METHODS:A systematic review of Medline for articles related to lumbar disc arthroplasty was conducted up to and including journal articles published in August 2003. In addition, the abstracts from the annual meetings of the North American Spine Society and Scoliosis Research Society from 1998 to 2003 were searched. The literature was then reviewed and summarized. RESULTS/CONCLUSIONS:Short-term results of lumbar disc arthroplasty as measured by pain relief and disability are good in some studies. Implants are relatively safe in the short term, and with newer designs complications are usually related to the surgical approach rather than early implant failure. Recovery times appear to be shorter than arthrodesis. Despite the relatively good early clinical results of these devices, questions remain about the long-term efficacy in pain relief and maintenance of motion, the results of randomized comparative trials with fusion and the life span of the devices. In addition, late sequelae and revision options are unknown. Current indications for lumbar disc arthroplasty are in the setting of a Food and Drug Administration trial in young, nonosteoporotic patients with one or two level symptomatic disc degeneration without severe facet arthropathy, segmental instability or neural element compression requiring a posterior decompression.
10.1016/j.spinee.2004.09.006
PREPARE: presurgery physiotherapy for patients with degenerative lumbar spine disorder: a randomized controlled trial.
Lindbäck Yvonne,Tropp Hans,Enthoven Paul,Abbott Allan,Öberg Birgitta
The spine journal : official journal of the North American Spine Society
BACKGROUND CONTEXT:Surgery because of disc herniation or spinal stenosis results mostly in large improvement in the short-term, but mild to moderate improvements for pain and disability at long-term follow-up. Prehabilitation has been defined as augmenting functional capacity before surgery, which may have beneficial effect on outcome after surgery. PURPOSE:The aim was to study if presurgery physiotherapy improves function, pain, and health in patients with degenerative lumbar spine disorder scheduled for surgery. STUDY DESIGN:A single-blinded, two-arm, randomized controlled trial (RCT). PATIENT SAMPLE:A total of 197 patients were consecutively included at a spine clinic. The inclusion criteria were patients scheduled for surgery because of disc herniation, spinal stenosis, spondylolisthesis, or degenerative disc disease (DDD), 25-80 years of age. OUTCOME MEASURES:Primary outcome was Oswestry Disability Index (ODI). Secondary outcomes were pain intensity, anxiety, depression, self-efficacy, fear avoidance, physical activity, and treatment effect. METHODS:Patients were randomized to either presurgery physiotherapy or standardized information, with follow-up after the presurgery intervention as well as 3 and 12 months post surgery. The study was funded by regional research funds for US$77,342. No conflict of interest is declared. RESULTS:The presurgery physiotherapy group had better ODI, visual analog scale (VAS) back pain, EuroQol-5D (EQ-5D), EQ-VAS, Fear Avoidance Belief Questionnaire-Physical Activity (FABQ-PA), Self-Efficacy Scale (SES), and Hospital Anxiety and Depression Scale (HADS) depression scores and activity level compared with the waiting-list group after the presurgery intervention. The improvements were small, but larger than the study-specific minimal clinical important change (MCIC) in VAS back and leg pain, EQ-5D, and FABQ-PA, and almost in line with MCIC in ODI and Physical Component Summary (PCS) in the physiotherapy group. Post surgery, the only difference between the groups was higher activity level in the physiotherapy group compared with the waiting-list group. CONCLUSIONS:Presurgery physiotherapy decreases pain, risk of avoidance behavior, and worsening of psychological well-being, and improves quality of life and physical activity levels before surgery compared with waiting-list controls. These results were maintained only for activity levelspost surgery. Still, presurgery selection, content, dosage of exercises, and importance of being active in a presurgery physiotherapy intervention is of interest to study further to improve long-term outcome.
10.1016/j.spinee.2017.12.009
Characteristics and mechanisms of resorption in lumbar disc herniation.
Arthritis research & therapy
Lumbar disc herniation (LDH) can be spontaneously absorbed without surgical treatment. However, the pathogenesis and physiological indications for predicting protrusion reabsorption are still unclear, which prevents clinicians from preferentially choosing conservative treatment options for LDH patients with reabsorption effects. The purpose of this review was to summarize previous reports on LDH reabsorption and to discuss the clinical and imaging features that favor natural absorption. We highlighted the biological mechanisms involved in the phenomenon of LDH reabsorption, including macrophage infiltration, inflammatory responses, matrix remodeling, and neovascularization. In addition, we summarized and discussed potential clinical treatments for promoting reabsorption. Current evidence suggests that macrophage regulation of inflammatory mediators, matrix metalloproteinases, and specific cytokines in intervertebral disc is essential for the spontaneous reabsorption of LDH.
10.1186/s13075-022-02894-8