Prospective evaluation of the course of disc herniations in patients with proven radiculopathy.

Although surgery is often recommended as the definitive treatment for radiculopathy when definite disc herniation is demonstrated with imaging techniques, complete improvement can occur with nonoperative treatment. However, what happens to the disc in the latter circumstance is not well defined. We report the first prospective study in subjects with proven radiculopathy and definite disc herniation who improve with nonoperative management to determine what occurs to the herniated disc material. Eighteen subjects with lower extremity pain or paresthesia, positive straight leg raising, weakness in a myotomal distribution, reflex asymmetry, or electromyogram evidence of radiculopathy were studied. Subjects were admitted to the study if computed tomography (CT) scanning demonstrated definite disc herniation corresponding to the side and level of the radiculopathy. After complete clinical improvement, repeat CT scan was performed at six to 18 months after the initial study. The CT scans were interpreted separately by two neuroradiologists. Disc herniations were characterized by size (large, moderate, or minimal); the presence of absence of free fragments; and location. Follow-up scans were compared with the original study and characterized as resolved, improved, or unchanged. Fourteen subjects completed the study, an additional three had operative treatment, and one refused repeat scanning. Subjects were followed an average of 30.4 months with no recurrence of radicular symptoms during this follow-up period in 13 patients. One had recurrence of symptoms at 21 months and surgery at 26 months. Six follow-up scans (43%) were interpreted as completely resolved, five (36%) as improved, and three (21%) as unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

Reflex sympathetic dystrophy syndrome secondary to L5 radiculopathy.

A 47-year-old woman developed radiating right lower extremity pain with weakness in the L5 myotomes. A CT scan, subsequent myelogram, and postmyelogram CT scan were reported as negative. Two months of bed rest diminished the radiating symptoms, but the weakness persisted. Three months post onset a severe burning dysesthesia developed in the right foot, and the patient became unable to bear weight on that extremity. Physical examination revealed 4-/5 weakness of the ankle dorsiflexors, foot evertors, toe extensors, and hip abductors. The entire right foot was swollen and had a red, mottled discoloration. An EMG was equivocal, and a three-phase bone scan was positive in the right foot in all three phases, which is characteristic of reflex sympathetic dystrophy. A repeat CT scan and review of the earlier scans revealed a high lateral disc fragment at the exit foramina of the L5 nerve root. Upon laminectomy, a free disc fragment at the exit foramina was removed, and the patient's symptoms resolved completely. Reflex sympathetic dystrophy syndrome is very rarely reported in association with lumbar radiculopathy. This case emphasizes the need to carefully evaluate the far lateral exit foramina on CT scan in patients with symptoms of radiculopathy. Myelogram is characteristically normal in these cases.

Regression of herniated nucleus pulposus: two patients with lumbar radiculopathy.

Thirty percent to 95% of patients with lumbar radiculopathy secondary to a bulging or herniated disc improve to a pain-free and functional level with nonsurgical treatment. What happens to the herniated disc material as this improvement occurs is unclear. We present two patients with lumbar radiculopathy documented by physical examination and electrodiagnostic testing. Both patients had herniated disc material at the L5 to S1 level on computed tomography (CT) scans corresponding to the side and level of their lesion on physical examination and electrodiagnostic testing. In both instances, the radiculopathy resolved with conservative treatment. CT scans were repeated in three months on one patient and four months on the other. The scans showed major resolution of the herniated disc material in both patients. These two cases demonstrate that in some patients with proven radiculopathy secondary to herniated nucleus pulposus, the herniated disc material will no longer be visible on CT scan and is presumed to resorb as the symptoms abate.

Temperature effect on antidromic and orthodromic sensory nerve action potential latency and amplitude.

The measurement of sensory nerve action potential (SNAP) latency and amplitude is often necessary to accurately diagnose disorders of peripheral nerves. The sensory evoked response can be obtained using either the antidromic (AD) or orthodromic (OD) technique. In a previous study we demonstrated that in healthy subjects the AD SNAP distal latency of median and ulnar nerves at 14 cm distance is approximately 0.2 msec slower than the OD SNAP distal latency at 32C. The AD SNAP amplitude was also two times greater than the OD SNAP amplitude. In this study we observed that these differences between the AD and OD SNAP latency and amplitude varied significantly as temperature changed. The AD median nerve SNAP distal latency was delayed by .06 msec/degree with cooling. The OD median nerve SNAP distal latency was delayed by .03 msec/degree with cooling. These values represent less of a slowing per degree centigrade cooling than has been previously noted in the literature. The median nerve SNAP amplitude was found to increase with upper extremity cooling with the AD and OD technique by 3.5 microV and 0.5 microV per degree, respectively. For accurate interpretation of SNAP latency and amplitude, the electromyographer must be familiar with the technique used and the differing effect of the temperature with each technique.

Gastric partitioning complicated by peripheral neuropathy with lumbosacral plexopathy.

Gastric bypass and partitioning are the two surgical procedures most commonly used in the treatment of morbid obesity. They are, however, not without their postoperative complications. These include acute and chronic problems such as wound infection, gastric leak, obstruction, embolism, and neurologic sequelae. Many studies have mentioned the frequent occurrence of polyneuropathy in the postgastrectomy state. This report describes a 38-year-old patient who developed an asymmetric peripheral neuropathy with lumbosacral plexus involvement following gastric bypass surgery for morbid obesity.

Orthodromic vs antidromic sensory nerve latencies in healthy persons.

Sensory nerve action potentials may be evoked antidromically (AD) by stimulating a nerve proximally and recording distally, or orthodromically (OD) by stimulating distally and recording over the nerve trunk proximally. The objective of this study was to compare OD and AD distal latencies in healthy subjects. Fifty-two volunteers (average age 30 years) were tested. Orthodromic and AD sensory distal latencies of the median and ulnar nerves of the nondominant hand were obtained. Hand temperature was controlled at 32C. Six subjects were also tested at a hand temperature of 24C. In all subjects tested the OD latency was shorter than the AD latency. Median nerve AD = 3.14 +/- 0.20 (mean latency in ms +/- 1 standard deviation); median nerve OD = 2.94 +/- 0.20; ulnar nerve AD = 3.07 +/- 0.22; ulnar nerve OD = 2.85 +/- 0.19. Mean difference between the latencies obtained (OD vs AD) for the median and ulnar nerves was statistically significant (p less than 0.001). In addition, this difference was over twice as great at 24C compared to 32C for both median and ulnar nerves. Because of the difference between OD and AD sensory latencies, the standard values obtained using one method cannot be rigorously applied when utilizing the other method. Individual laboratories should develop their own normal values for both OD and AD methods, or be specific in performance of the studies when utilizing standards from the literature.

Cheiralgia paresthetica and linear atrophy as a complication of local steroid injection.

Cheiralgia paresthetica, a mononeuropathy of the superficial branch of the radial nerve, is an uncommon problem, usually resulting from local trauma to the wrist. This report describes a 27-year-old patient who developed subdermal atrophy following local hydrocortisone injection as a treatment for deQuervain's tenosynovitis. Subsequently, she developed linear skin atrophy, a rare complication of steroid injection thought to result from lymphatic spread of the steroid suspension, extending proximally from the initial atrophic area in her hand into her forearm. Soon after wearing a wristwatch on the affected wrist, she developed symptoms of cheiralgia paresthetica. Linear atrophy was found to traverse the superficial radial nerve and was considered to contribute to the symptoms. It is important to be aware that subcutaneous atrophy may follow the lymphatics with injections of steroid.

Dynamic approach in the diagnosis of thoracic outlet syndrome using somatosensory evoked responses.

The clinical diagnosis of thoracic outlet syndrome (TOS) is controversial. Objective documentation of this disorder is often unobtainable, even with electrodiagnostic techniques. This preliminary report describes an objective diagnostic method of evaluating TOS using somatosensory evoked potential testing (SEP) and dynamic arm positioning. Evoked potentials were recorded over the brachial plexus (N9) and C7 cervical vertebra (N13) after distal stimulation of the median and/or ulnar nerves. This was performed with the arm both at the side (anatomic position), and then positioned in abduction and external rotation. Absolute and interpeak latencies were measured in both positions. Of 14 patients clinically suspected of having TOS, six showed normal N13 evoked responses in the anatomic position despite a disappearance of this potential when tested with the symptomatic arm in the dynamic position of abduction and external rotation. Fourteen control subjects had normal responses with the arm tested in both positions. The SEP coupled with the dynamic stress of the nerves coursing through the thoracic outlet may be helpful as a new objective aid in the diagnosis of TOS.

Hajdu-Cheney syndrome: rehabilitation after decompression of cervical spinal cord compromise.

Cervical spinal cord compromise can be caused by many pathologic conditions. In this case report, a patient with Hajdu-Cheney syndrome, an exceedingly rare disorder of bony elements which led to basilar skull invagination and subsequent cervical cord compression, is described. Postoperatively, the patient continued to have difficulty with self-care and ambulation and required an extensive rehabilitation program which included mat activities, progressive resistive exercises, activities of daily living, and gait training. She was able to become independent in transfers, ambulation, and activities of daily living. The patient's rehabilitation course after cervical spinal cord decompression is presented, along with a brief description of the clinical features of this unusual disease process.

Influence of dopamine infusion on plasma prolactin released by kidney capsule transplanted anterior pituitaries.

The infusion of dopamine into the renal artery resulted in decreased prolactin release from 3 anterior pituitary glands transplanted under the kidney capsule. Prolactin levels continually decreased over a 5 min period after DA infusion was terminated and thereafter approached preinfusion levels by the end of 10 min.