Differences in Gait Characteristics of Patients with Lumbar Spinal Canal Stenosis (L4 Radiculopathy) and Those with Osteoarthritis of the Hip

It is important to differentially diagnose thigh pain from lumbar spinal stenosis (particularly lumbar fourth nerve root radiculopathy) and osteoarthritis of the hip. In this study, using a treadmill and a motion analysis method, gait characteristics were compared between these conditions. Patients with lumbar fourth nerve root radiculopathy had increased physiological knee flexion immediately after foot-ground contact, possibly owing to a slight decrease in the muscle strength of the quadriceps femoris muscle. Patients with osteoarthritis of the hip had decreased range of motion of the hip joint probably due to anatomically limited mobility as well as gait strategy to avoid pain resulting from increased internal pressure on the hip joint during its extension. Our facile and noninvasive method can be useful for the differential diagnosis of lumbar spinal canal stenosis from osteoarthritis of the hip.     

Neurologic Complications of Paget Disease of Bone

ObjectiveTo review the epidemiology, evaluation, and management of the neurologic complications associated with Paget disease of bone (PDB).MethodsWe reviewed the English-language medical literature using MEDLINE data sources from 1950 to August 2008 and manually searched cross-references from original articles and reviews. Search terms included “Paget* disease of bone” and “neurologic* complications,” “cranial nerve,” “spinal cord,” or “peripheral nerve.”ResultsSeveral neurologic problems in the central and peripheral nervous systems may complicate PDB. Up to 76% of patients may have some form of neurologic involvement. Neurologic complications can occur in patients with a long history of PDB as well as in patients with previously unrecognized disease. The primary mechanisms of nerve damage in PDB involving the spine are ischemic myelitis and compression due to bone hypertrophy. Evaluation includes determining the serum alkaline phosphatase level and imaging by radiography, bone scintigraphy, computed tomographic scanning, and, for lesions of the central nervous system, magnetic resonance imaging. If a soft-tissue mass is found, biopsy should be considered to exclude the presence of sarcoma. Treatment strategies include calcium, vitamin D, bisphosphonates, and possibly surgical intervention for refractory cases.ConclusionNeurologic sequelae of PDB may be underappreciated. Despite the paucity of data guiding treatment, zoledronic acid is a reasonable first-line therapy. Lack of response to treatment or relapse should prompt diagnostic reevaluation with a heightened suspicion for tumor. (Endocr Pract. 2009;15:158-166)     

Accidental finding of an anomalous spinal nerve root during lumbar-disc surgery: a case report and a review of literature

Anomalies of lumbosacral nerve roots, even though are rare, have been well documented so far in the medical literature. The early diagnosis of these anomalies may be difficult and it is crucial to develop specific methods for depicting them. Preoperative diagnosis of anomalous lumbosacral spinal nerve roots using the magnetic resonance imaging is essential to facilitate thorough surgical planning in order to avoid unnecessary complications for the patient during surgery. The operative management of these anomalies depends on the patient's neurological problems and while asymptomatic and accidentally diagnosed cases do not require treatment, patients who suffer low back or sciatic pain need surgical intervention in order to decompress nerve roots. We report a 45-years old woman presented with severe low back pain associated with left lumboischialgia. Intraoperative finding of an aberrant L5/S1 nerve root, optimal surgical therapy and different classifications are discussed together with a review of literature.     

Trial of an Anti-inflammatory Agent (Indomethacin) in Low Back Pain with and without Radicular Involvement

A short-term double-blind sequential trial of indomethacin against placebo in the treatment of low back pain, with and without nerve root pain such as sciatica, showed that indomethacin was significantly more effective than placebo in the group with nerve root pain. On the other hand, no difference was found between the treatments in the patients with uncomplicated low back pain. This difference may result from an effect of indomethacin on the inflammatory process around the nerve root which has been shown to be present when this is compressed.     

Weak Ankles. A Study of Common Peroneal Entrapment Neuropathy

Twenty-three patients were seen with entrapment neuropathy in a two-and-a-half-year period. Symptoms consisted of pain, paresis, and paraesthesia in the distribution of the common peroneal nerve. Some degree of paresis was often present, which in five patients was severe enough to cause drop foot. In 20 patients decompression of the entrapped nerve at the neck of the fibula was quickly and completely successful. It is suggested that the ankle weakness which frequently follows sprains and other forced inversion injuries may often be at least partially due to entrapment of the common peroneal nerve.     

Relationship between the blood flow in a spinal nerve root and its functional state in patients with lumbar disk hernia

Capillary blood flow in the spinal roots was studied in 52 patients with lumbar osteochondrosis during discectomy for lumbar disk herniation, before and after decompression. It was determined that the value of the capillary blood flow in the nerve root influenced markedly the severity of the pain syndrome, the threshold of sensitivity to pain in the dermatome involved, and the strength of the indicator group of muscles. It was shown that the level of intact reserves of the spinal nerve root microcirculation influenced the degree of functional restoration after the discectomy.     

经皮椎间孔镜TESSYS术与TLIF术治疗腰椎间盘突出症合并神经根管狭窄的疗效对比研究

摘要 目的：对比经皮椎间孔镜TESSYS术与经椎间孔入路腰椎椎体间融合术（TLIF）治疗腰椎间盘突出症（LDH）合并神经根管狭窄的疗效。方法：回顾性分析2016年4月~2019年4月期间徐州医科大学附属沭阳医院收治的96例LDH合并神经根管狭窄患者的临床资料,根据手术方式的不同将患者分为A组（n=48,采用TLIF术式治疗）和B组（n=48,采用经皮椎间孔镜TESSYS术治疗）,比较两组优良率、视觉疼痛模拟评分（VAS）、Oswestry 功能障碍指数（ODI）、椎间高度、滑脱程度、隐神经、腓肠神经等感觉神经传导速度（SCV）和胫神经、腓总神经等运动神经传导速度（MCV）,记录两组并发症发生情况。结果：B组优良率高于A组（P<0.05）。两组患者术后6个月VAS评分、ODI评分以及滑脱程度均降低,且B组低于A组（P<0.05）。两组患者术后6个月椎间高度、隐神经SCV、腓肠神经SCV、胫神经MCV、腓总神经MCV升高,且B组高于A组（P<0.05）。B组并发症发生率低于A组（P<0.05）。结论：与TLIF术式相比,经皮椎间孔镜TESSYS术治疗LDH合并神经根管狭窄的疗效显著,可有效减轻患者疼痛,提高腰背功能,明显改善双下肢神经功能,提高筋膜代偿能力,且并发症发生率更低,临床应用价值更高。     

Distinct roles of matrix metalloproteases in the early- and late-phase development of neuropathic pain

Treatment of neuropathic pain, triggered by multiple insults to the nervous system, is a clinical challenge because the underlying mechanisms of neuropathic pain development remain poorly understood. Most treatments do not differentiate between different phases of neuropathic pain pathophysiology and simply focus on blocking neurotransmission, producing transient pain relief. Here, we report that early- and late-phase neuropathic pain development in rats and mice after nerve injury require different matrix metalloproteinases (MMPs). After spinal nerve ligation, MMP-9 shows a rapid and transient upregulation in injured dorsal root ganglion (DRG) primary sensory neurons consistent with an early phase of neuropathic pain, whereas MMP-2 shows a delayed response in DRG satellite cells and spinal astrocytes consistent with a late phase of neuropathic pain. Local inhibition of MMP-9 by an intrathecal route inhibits the early phase of neuropathic pain, whereas inhibition of MMP-2 suppresses the late phase of neuropathic pain. Further, intrathecal administration of MMP-9 or MMP-2 is sufficient to produce neuropathic pain symptoms. After nerve injury, MMP-9 induces neuropathic pain through interleukin-1beta cleavage and microglial activation at early times, whereas MMP-2 maintains neuropathic pain through interleukin-1beta cleavage and astrocyte activation at later times. Inhibition of MMP may provide a novel therapeutic approach for the treatment of neuropathic pain at different phases.     

Dropped head syndrome due to myogenic atrophy --- a case report of surgical treatment

Osteoid osteoma of the spine is a relatively rare bone-forming tumor. Pain that is worse at night and relieved by aspirin and muscle contracture are the most characteristic symptoms of spinal osteoid osteoma. Although radicular pain occasionally occurs in spinal osteoid osteoma, spinal cord and nerve root compression is absent in most cases. Although radicular pain appears to be associated with tumorous inflammation, there have been no presentations of histological findings of inflammation around the nerve root. We present here two rare cases of spinal osteoid osteoma causing radiculopathy and the first histological evidence of tumorous inflammation as a cause of radiculopathy in osteoid osteoma near the intervertebral foramen.     

Separate populations of primary sensory neurons project to the splanchnic nerve and thoracic spinal nerve rami of the rat. A fluorescent double labelling study

Using fluorescent double labelling technique with one tracer applied to the greater splanchnic nerve and a second to the ventral or dorsal spinal nerve ramus at the T9 level, it was shown that two separate populations of sensory nerve cell bodies in the T9 dorsal root ganglion were projecting to the splanchnic nerve and spinal rami, respectively. Only two double labelled cells were detected. The results support the theory that spinal and/or supraspinal interactions and not dichotomizing sensory axons are responsible for referred pain.     

Carcinomatous Neuromyopathy—The Non-Metastatic Effects of Cancer on the Nervous System

Cancer can produce a variety of effects on the nervous system either by direct compression or invasion, or remotely by some as yet unknown metabolic, toxic, viral or immunologic effect on the nervous system. The neurologic effects associated with cancer that does not directly involve neural tissue have distinctive features that can give the first clue to a previously undiagnosed neoplasm. Physicians who see patients with neurologic illness should be aware that there may be an underlying malignant lesion giving rise to the neurologic syndrome; and conversely they should be on the alert for neurologic complications in patients with known cancer even though the lesion does not directly press upon or invade nerve tissue.     

Progranulin contributes to endogenous mechanisms of pain defense after nerve injury in mice

Progranulin haploinsufficiency is associated with frontotemporal dementia in humans. Deficiency of progranulin led to exaggerated inflammation and premature aging in mice. The role of progranulin in adaptations to nerve injury and neuropathic pain are still unknown. Here we found that progranulin is up-regulated after injury of the sciatic nerve in the mouse ipsilateral dorsal root ganglia and spinal cord, most prominently in the microglia surrounding injured motor neurons. Progranulin knockdown by continuous intrathecal spinal delivery of small interfering RNA after sciatic nerve injury intensified neuropathic pain-like behaviour and delayed the recovery of motor functions. Compared to wild-type mice, progranulin-deficient mice developed more intense nociceptive hypersensitivity after nerve injury. The differences escalated with aging. Knockdown of progranulin reduced the survival of dissociated primary neurons and neurite outgrowth, whereas addition of recombinant progranulin rescued primary dorsal root ganglia neurons from cell death induced by nerve growth factor withdrawal. Thus, up-regulation of progranulin after neuronal injury may reduce neuropathic pain and help motor function recovery, at least in part, by promoting survival of injured neurons and supporting regrowth. A deficiency in this mechanism may increase the risk for injury-associated chronic pain.     

中医药外治法在腰椎管狭窄症中的应用

腰椎管狭窄症是由于腰椎的骨与软组织因某种原因而发生形态与组织结构方面的变化,造成椎管容积变小,导致脊神经根受到机械性压迫而出现特有的临床症状的一种疾病。本文拟通过对近年来腰椎管狭窄症的研究文献的分析、总结,从针刺、推拿、注射、牵引等对腰椎管狭窄症的中医药外治现状进行总结,旨在指导临床治疗。     

Adult peripheral nerve disorders: nerve entrapment, repair, transfer, and brachial plexus disorders

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Describe the pathophysiologic bases for nerve injury and how they apply to patient evaluation and management. 2. Recognize the wide variety of injury patterns and associated patient complaints and physical findings associated with peripheral nerve pathology. 3. Evaluate and recommend further tests to aid in defining the diagnosis. 4. Specify treatment options and potential risks and benefits. SUMMARY: Peripheral nerve disorders comprise a gamut of problems, ranging from entrapment neuropathy to direct open traumatic injury and closed brachial plexus injury. The pathophysiology of injury defines the patient's symptoms, examination findings, and treatment options and is critical to accurate diagnosis and treatment. The goals of treatment include management of the often associated pain and improvement of sensory and motor function. Understanding peripheral nerve anatomy is critical to adopting novel nerve transfer procedures, which may provide superior options for a variety of injury patterns.     

Posttraumatic Syringomyelia

Posttraumatic syringomyelia is becoming increasingly recognized as a sequel to major and minor spinal cord injury, paralleling the development and widespread availability of magnetic resonance imaging as a diagnostic modality for evaluating possible spinal pathologic lesions. Delayed, subacute, or progressive neurologic deterioration in victims of traumatic spinal injury with “fixed deficits” should raise the suspicion of posttraumatic syringomyelia. Alternatively, it may present as sensory or motor complaints occurring on a delayed basis after minor spinal trauma causing no initial neurologic impairment. At our institution, we have treated six of eight patients with this condition by shunting fluid from the intramedullary cyst to the peritoneal cavity by means of a simple valveless shunt, resulting in sustained neurologic improvement in five patients.     

Abnormal physiology of the dorsal horn as related to the deafferentation syndrome

The spinal cord dorsal horn has been implicated in the generation of pain and dysesthesias following nerve and nerve root damage and/or avulsion, as well as following damage in adjacent spinal cord regions. Alterations in the functional properties of dorsal horn neurons occur after deafferentation and may underlie the occurrence of abnormal sensations referred to the denervated body part. Abnormal activity following deafferentation has also been noted at thalamic and cortical levels. Some of these post-denervation functional changes, determined anatomically and/or electrophysiologically, are reviewed as well as the results of behavioral studies of the deafferentation syndrome in the rat.     

Recent evidence for activity-dependent initiation of sympathetic sprouting and neuropathic pain

Traumatic injury or inflammatory irritation of the peripheral nervous system often leads to persistent pathophysiological pain states. It has been well-documented that, after peripheral nerve injury or inflammation, functional and anatomical alterations sweep over the entire peripheral nervous system including the peripheral nerve endings, the injured or inflamed afferent fibers, the dorsal root ganglion (DRG), and the central afferent terminals in the spinal cord. Among all the changes, ectopic discharge or spontaneous activity of primary sensory neurons is of great clinical interest, as such discharges doubtless contribute to the develop-ment of pathological pain states such as neuropathic pain. Two key sources of abnormal spontaneous activity have been identified following peripheral nerve injury: the injured afferent fibers (neuroma) leading to the DRG, and the DRG somata. The purpose of this review is to provide a global account of the abnormal spontaneous activity in various animal models of pain. Particular attention is focused on the consequence of peripheral nerve injury and localized inflammation. Further, mechanisms involved in the generation of spontaneous activity are also reviewed; evidence of spontaneous activity in contributing to abnormal sympathetic sprouting in the axotomized DRG and to the initiation of neuropathic pain based on new findings from our research group are discussed. An improved understanding of the causes of spontaneous activity and the origins of neuropathic pain should facilitate the development of novel strategies for effective treatment of pathological pain.     

Dorsal root entry zone lesions in the treatment of pain following brachial plexus avulsion, spinal cord injury and herpes zoster

This paper details the long-term results in patients treated with dorsal root entry zone (DREZ) lesions for the treatment of pain following brachial plexus avulsion, spinal cord injury, and herpes zoster. With our current operative technique, 82% of patients with brachial plexus avulsion injuries were afforded long-term pain relief. Patients with pain confined to dermatomes just below the level of spinal injury also did well with DREZ lesions, although the results were less good in patients with diffuse pain or with sacral pain. The postoperative results in patients with postherpetic pain were disappointing.