Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain

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). (aut. ref.

Assessment of nerve involvement in the lumbar spine: agreement between magnetic resonance imaging, physical examination and pain drawing findings

<p>Abstract</p> <p>Background</p> <p>Detection of nerve involvement originating in the spine is a primary concern in the assessment of spine symptoms. Magnetic resonance imaging (MRI) has become the diagnostic method of choice for this detection. However, the agreement between MRI and other diagnostic methods for detecting nerve involvement has not been fully evaluated. The aim of this diagnostic study was to evaluate the agreement between nerve involvement visible in MRI and findings of nerve involvement detected in a structured physical examination and a simplified pain drawing.</p> <p>Methods</p> <p>Sixty-one consecutive patients referred for MRI of the lumbar spine were - without knowledge of MRI findings - assessed for nerve involvement with a simplified pain drawing and a structured physical examination. Agreement between findings was calculated as overall agreement, the p value for McNemar's exact test, specificity, sensitivity, and positive and negative predictive values.</p> <p>Results</p> <p>MRI-visible nerve involvement was significantly less common than, and showed weak agreement with, physical examination and pain drawing findings of nerve involvement in corresponding body segments. In spine segment L4-5, where most findings of nerve involvement were detected, the mean sensitivity of MRI-visible nerve involvement to a positive neurological test in the physical examination ranged from 16-37%. The mean specificity of MRI-visible nerve involvement in the same segment ranged from 61-77%. Positive and negative predictive values of MRI-visible nerve involvement in segment L4-5 ranged from 22-78% and 28-56% respectively.</p> <p>Conclusion</p> <p>In patients with long-standing nerve root symptoms referred for lumbar MRI, MRI-visible nerve involvement significantly underestimates the presence of nerve involvement detected by a physical examination and a pain drawing. A structured physical examination and a simplified pain drawing may reveal that many patients with "MRI-invisible" lumbar symptoms need treatment aimed at nerve involvement. Factors other than present MRI-visible nerve involvement may be responsible for findings of nerve involvement in the physical examination and the pain drawing.</p

Assessment of correlation between spinal canal shape and spinal cord injury in thoracolumbar spine fractures

Traumatic spinal cord injury is one of the important causes of disability. In some of vertebral fractures, spinal canal is deformed and compromised. The relationship between the shape of the cervical canal and spinal cord injury has been proved but such a correlation for thoracolumbar spine has not been documented yet. Thus, 100 consecutive patients with traumatic fracture of thoracolumbar spine [50 patients with compromised canal (cases) and 50 patients with intact canal] were evaluated in the light of spinal canal shape (Using CT scan), neurological defects (Using Frankle classification), mechanism of trauma and level of the spinal fracture. Of the 100 patients studied, 23 had spinal cord injury and most of injuries were at T12-L2. The most common mechanisms of trauma were road traffic accident and fall. The difference in age, sex and mechanism of trauma between the two groups was not statistically significant. No significant difference was found between canal intact group and canal compromised group in neurological deficit (P=0.09). In traumatic spinal cord injury, it seems that dynamic spinal canal encroachment is more important than static canal compromise. Keywords: Spinal cord injury, Thoracolumbar spine, Neurological defici

Evaluation of correlation between cases of depressed fracture and associated brain lesion

This cross-sectional study was performed on 382 patients with depressed skull fracture admitted to the neurosurgery ward of Kerman Bahonar Hospital between 1994 and 1999. 329 of the patients (86.1%) had open fractures, while the fracture was of closed type in 53 cases (13.9%). Of those with open fracture, 42% were associated with dura tearing, whereas the rate was 34% in closed fractures. The most common causes of depressed fracture were accidents with motor vehicles (59.4%). In most cases (77%) Glasgow Coma Scale (GCS) on admission was 13-15. There was no associated lesion in 247 patients (64.7%), but 135 (35.3%) had one or more lesions, with contusion (34%) and epidural hematoma (23.7%) as the most common ones. In cases when the fracture was caused by motor vehicle accidents, the occurence of clinical manifestations was more than that of the other causes. Of 15 patients who died (3.9%) 14 cases (93.3%) had associated lesions. Keywords: Depressed fracture, Brain lesion, Clinical sig

Effect of Aspirin on Spinal Cord Injury: An Experimental Study

Aspirin is an anti-inflammatory drug, peroxyl radical scavenger, and antioxidant agent that inhibits phospholipases, nitric oxide synthetases, and cyclooxygenase enzymes. The existing literature contains no studies on the effects of various doses of aspirin on spinal cord injury (SCI). Therefore, we sought to investigate the putative effects of aspirin on experimental SCI. The weight-drop injury model was used to produce SCI in 100 albino Wistar rats. The animals were allocated to five groups: a control group, where the rats did not undergo any surgical or medical intervention except for anesthesia; a sham-treated group, where laminectomy was performed without SCI and no further therapy was administered; and three other groups, where the rats with SCI received low-dose aspirin [20 mg/kg], high-dose aspirin [80 mg/kg], and a vehicle, respectively. Half of the rats were sacrificed 24 hours later, and their spinal cords were excised for biochemical studies. The other rats were subjected to Basso, Beattie, and Bresnahan (BBB) locomotor rating scale scoring once a week for 6 consecutive weeks. Aspirin decreased lipid peroxidation following SCI as the mean (± standard error) catalase level was significantly higher in the high-dose aspirin group (46.10±12.01) than in the sham-treated group (16.07±2.42) and the vehicle-treated group (15.31±3.20) (P<0.05; P<0.05, respectively). Both of the groups treated with high-dose and low-dose aspirin demonstrated a higher mean BBB score than did the control group (P<0.001) and the sham-treated group (P<0.001). Our data provide evidence in support of the potential effects of aspirin in biochemical and neurobehavioral recovery after SCI

Mature teratoma of conus medullaris: A case report and review of literature

Key Clinical Message In conus medullaris, mature teratomas are rare. We report a case of a 40‐year‐old man who presented with urinary incontinence, low back pain, and muscle weakness. Magnetic resonance imaging revealed a mass in conus medullaris (T11–L1), further confirmed as a mature teratoma by pathological examination. We identified 63 cases of conus medullaris teratoma over the past two decades by systematically analyzing the case reports. Findings demonstrated that most cases were diagnosed in the fourth decade of life, with the majority of cases (57.6%) being male. Lower back pain, radiating pain in the extremities, hypoesthesia, and urinary dysfunction are the most common clinical presentations among patients with teratoma of conus medullaris. Mature teratoma is the dominant pathologic subtype of teratomas in this region, comprising more than 95% of cases. Our case highlights the importance of considering spinal teratoma as a differential diagnosis in patients presenting with urinary incontinence and lumbar pain

Pesticide Exposure and Head and Neck Cancers: A Case-Control Study in an Agricultural Region

Introduction: Causes of head and neck cancers (HNCs) are multifactorial, and few studies have investigated the association between chemical exposure and HNCs. The objective of this study was to investigate associations between HNCs, agricultural occupations, and pesticide exposure. The potential for the accumulation of pesticides in the adipose tissue of patients was also investigated.   Materials and Methods: A structured questionnaire was used to collect information on demographics, occupation, and exposure to pesticides in a hospital-based case-control study. Pesticide residue in the adipose tissue of the neck in both cases and controls was also monitored via gas chromatography–mass spectroscopy.   Results: Thirty-one HNC cases were included in this study as well as 32 gender-, age-, and smoking-matched controls. An agricultural occupation was associated with HNC (odds ratio [OR], 3.26; 95% confidence interval [CI], 1.13–9.43) after controlling for age, sex, and smoking. Pesticide exposure was associated with total HNC cases (OR, 7.45; 95% CI, 1.78–3.07) and larynx cancer (OR, 9.33; 95% CI, 1.65–52.68). A dose-response pattern was observed for HNC cases (P=0.06) and larynx cancer (P=0.01). In tracing the pesticide residue, five chlorinated pesticides, namely dichlorodiphenyltrichloroethane (DDT), dichlorodipheny-ldichloroethane (DDD), dichlorodiphenyldichloroethylene (DDE), dieldrin, and lindane, were identified in the adipose tissue. Chlorinated pesticide detection was significantly associated with HNC (OR, 3.91; 95% CI 0.9–0.16.9).   Conclusion: HNCs were found to be associated with pesticide exposure after controlling for confounders. A high education level was identified as a modifying factor decreasing the risk of HNCs. Further studies with larger number of subjects are recommended to assess these relationships in greater detail