malformation of lumbar spinal roots sheaths sciatica - The Bone ...

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that lumbar root compression, resulting in pain in the lumbar region and sciatica, may be caused by a variety of lesions, such as herniation of intervertebral discs,.
MALFORMATION IN

OF

THE

SVEN

It

is

discs, also

well

and

known

Within

recent

years

the

of

we

problem

cases the

those have

of low

of malformation

found been

back

in

unable pain

the

and

Hospital,

such

and

pain

in

roots

and

and

lumbar

In

described

It

is

radiculitis.

sheaths which

above.

malformations

the

intervertebral

neurinomata.

adhesion

changes

mentioned

of

spinal

of lumbar clinical

such

in

of root

conditions find

A arhus

as herniation

in cases

displaying to

DENMARK

osteochondrosis develop

SCIATICA

resulting

of lesions,

may

authors,

City

compression,

flavum,

symptoms

four

from

literature

a variety

ligamentum

identical

observation

indistinguishable

root

by

AARHUS, at the

SHEATHS

AND AND

RIISHEDE,

of Neurosurgery

lumbar

ROOTS

BACKACHE

JOHN

Department

be caused

of the that

LOW

and

that

may

recent

the

State

established

sciatica,

hypertrophy well

under

with

the

SPINAL

OF

ETHELBERG

From

region

LUMBAR

CAUSATION

have are

come grossly

reviewing

the

in conjunction

sciatica. CASE

REPORTS

Case 1-Woman aged thirty-one years. At the age of nineteen she had for a period of about three months suffered from a dull pain in the back of the right thigh and calf. This was relieved by manipulation. Eighteen months before entering hospital she began to complain of pain in the lumbar region. Some months later the pain began to pass to the back of the right thigh, and eventually also to the calf and the great toe. She had noticed a transitory tingling numbness in the right foot. The pain was made worse by coughing, sneezing and by bending forwards. Repeated manipulations had led to no improvement. Examination-There was obliteration of the lumbar lordosis. The range of spinal movements was slightly limited. There was no local tenderness. No weakness or disorder of sensation was revealed in the lower limbs. Deep reflexes were all normal. Straight leg raising was slightly impaired and painful on the right. Lumbar puncture revealed normal pressure conditions. The cerebro-spinal fluid was clear, and the cell count and protein content were normal. Radiographs showed slight narrowing of the fourth and fifth lumbar intervertebral discs, but no other abnormality. A diagnosis of herniated intervertebral disc in the lower lumbar region was made. Operation-Laminectomy of the fourth and fifth lumbar vertebrae was performed. No protrusion of the two lower intervertebral discs could be found, but a peculiar affection of the fifth lumbar and first sacral nerve roots was seen (Fig. 1 ) . From the region where the fifth lumbar root normally shoots

off,

a dural

pouch

extended

laterally

for

about

half

an

inch.

In

this

were

contained

the

fifth lumbar and first sacral roots which, more distally, separated into distinct nerves, each passing through its normal intervertebral foramen. Cranio-caudally the pouch measured about threequarters of an inch, and ventro-dorsally a little less than half an inch. When the pouch had been opened both nerve roots were seen to be covered by a thin arachnoidal sheath ; the fifth lumbar root lay most ventrally and passed laterally ‘ ‘ below ‘ ‘ the first sacral root. There was no thickening of the sheaths or nerves. But ventro-dorsally the pouch with its contents was a little more than twice as thick as a normal root. The dura was closed. The decompression effected by the laminectomy was thought to be adequate treatment. Progress-Apart from a transient retention of urine the post-operative course was uneventful. She was transferred to her county hospital on the fifth day after operation. At that time she had no pain, and the neurological condition was unchanged. When readmitted almost a year later she

related

that

in

the

first

month

after

operation

she

had

felt

quite

well.

But

after

discharge

from her county hospital she began to notice a sharp stabbing pain in the left gluteal region. The pain was made worse by straining, stooping and coughing, and would then pass to the small of the back and to the back of the left leg. At intervals the left leg became numb, and the muscles of the right calf felt cramped. On examination there was still some limitation of movement of the lumbar spine, and there was tenderness on percussion over the third lumbar spinous process. There was slight weakness of 442

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

MALFORMATION

OF

LUMBAR

SPINAL

ROOTS

AND

SHEATHS

IN

LOW

BACKACHE

AND

443

SCIATICA

dorsiflexion of the foot on the right. Sensation and co-ordination were normal in both lover limbs. Straight leg raising was restricted by pain on the left. Lumbar puncture showed no abnormalities as regards pressure, cell count or protein content of the cerebro-spinal fluid. Radiographs showed the condition after a lumbar laminectomy. Myelography showed an incomplete hold-up of the contrast medium at the level of the lower border of the fourth lumbar body. There was no typical configuration of the radio-opaque medium such as may be seen in intraspinal turnours or arachnoiditis. Opera/ion-The previous laminectomy wound was reopened. The dural malformation on the right was unchanged. The dura was opened. The fifth lumbar and first sacral roots were lying separately, divided from the remaining roots by a thin membranous covering. \Vhen this was opened the roots of the cauda equina were seen to be the seat of a marked adhesive radiculitis (Fig. 2).

Case Figure

The

1.

Figure 1-Abnormal 2-The same case with a thin arachnoidal

lesion

together

was

with

classified

Progress-After had

no

as

an adhesive the

pain,

but

dural sac, containing the dura opened. layer. Adhesions

a malformation

radiculitis,

operation

of

which

a transient

complained

of

fifth Abnormal between

was

the

nerve

not

considered

retention

numbness

in

lumbar and first roots shielded the roots of the

of

the

back

roots

and due

urine

of

sheaths to

again

the

sacral roots on from the cauda cauda equina.

right

in

the

iodized developed.

right. by

lumbar

region,

contrast

the

thigh,

the equina

On

where

medium.

discharge a

doubtful

she loss

of sensation to touch and pain was disclosed. Two and a half years later she reported that the pain in the lumbar region and in the leg was unchanged. She complained of further pain in the left foot. The pain was made worse by straining. There had been no sphincter disturbances since one year after operation. She was able to do light work. On examination there was marked stiffness of the lumbar spine and a mild lumbar scoliosis. Straight leg raising was limited and painful on the

left,

and

Case 2-Man stumbling, had

no

pain

there aged

when

was

lifting

in the

slight

wasting

forty-seven back

years.

a heavy until

the

of

the

left

Ten

leg.

months

weight.

He

following

day.

felt

The

before a ‘ ‘ twang

Since

then

sensory

disorders

admission ‘ ‘

he

he

in the

had

suffered

lower

were had

unchanged.

twisted

part from

his

of the an

almost

back

back,

by

but

constant

pain in the lumbar region. Two months later the pain passed to the back of the left thigh and the anterior aspect of the left leg as far as the ankle. Pain was aggravated by stooping, coughing and Sneezing, but not by straining. He complained of” pins and needles “in the left leg. Manipulations and a course of x-ray therapy did not improve his condition. Examination-There was reduction of the lumbar lordosis, and movements were slightly restricted in the lumbar spine. There was no weakness or muscular wasting in the legs. The straight leg VOL.

34 B,

NO.

3,

AUGUST

1952

444

S.

raising

test

anterior no

was

side

of

pressure

were

disclosed

(Fig.

and

3).

This The

normal.

no

block

showed

The

fifth

lumbar

was

made

with

network

dura

of roots

‘as

left

There

upwards

to

; the

no

root

the

was

fluid in

sacral

root,

which over

had

I

;

:

y, y\

4 I\.

p

-

,

/,

tender

.

..

there

between roots. nerve

sacral sacral

lumbar

The

herniation

Progress-She On discharge the operation

Two

This and

to

months made

weakness

of or

Lxanination-There obliterated.

Spinal

were

its

a large

caudal

and

a small

intervertebral

to

in side

readmission by

foot.

‘as

slight

movements

back

; the the

that

previous

left

the

all full.

leg

he

ache

had

was

felt

had heavy

obliterated

There

lumbar spinous In the lower wasting; the Sensation

abnormality.

of

fifth

the

and tenderness

was

processes. limbs there left to

patellar touch

and first negative.

Spinal was no reflex pain

and

was was

sacral dermatomes. Lumbar puncture

root

sheath

on

over

of the

large

atrophic

the

were

nucleus

she

foot

began

to

sneezing

scoliosis were

some

leg. get and

to the full.

days

They

There

after were

pain

the most

in the

was

in appearance.

in

bed

for

Later

disc.

she

was

lumbar

region

and

the

same

time

lumbar

spine;

weakness

of

dorsiflexion

two

these

when

JOURNAL

of

weeks.

later. Six months that numbness

operation.

patellar reflex was diminished. There was loss of sensation to touch and and first sacral dermatomes. Lumbar puncture showed no abnormality. defective filling on the left at the level of the fifth lumbar intervertebral have a herniation of the fifth lumbar intervertebral disc, or a recurrent

diagnosis

intervertebral

kept

of the

THE

normal

marked

At the

coughing.

right

left

was

A

pulposus.

and she returned to work a month for further treatment. She stated left

she

right.

herniated

county

left

where

intervertebral

well,

the

hospital,

disc a

marked space.

showed

lumbar

was made. intervertebral

passing

most

Radiographs

fourth

lumbar

disc lumbar

with

the of

lordosis kyphosis.

her

stooping,

left

he reported

operation

operation

muscular diminished.

no

dorsally,

together

lateral

the

of

displaced

developed

worse of

was

she felt quite was readmitted

before

roots

From

.

intervertebral and the fifth

transferred

the

herniated

nerve

protruding

impaired in the right fifth lumbar The straight leg raising test was

filling

removed,

was

had

passed was

root

home she

1)araesthesiae had

defective

was

content

of

angle.

up into

the

lumbar

were

narrowing

fifth

the

a slight

revealed

fourth lumbar first sacral root

in

lumbar

was

weakness questionably

3

Case 2-Plexiformconnection

The

split slightly

after

Since

on percussion movements

-

.

showed

protein

A diagnosis

of the

the

spot

Examination-The

, ..

of the

and

revealed

and clumsy. Paraesthesiae were present only in the lateral toes of the left foot when he was lying down. On examination there was still some stiffness of the lumbar spine ; no muscular wasting or loss of motor power. No reflex disorders or sensory disturbances. Straight leg raising test was normal on both sides. Two years after operation there was no pain but numbness persisted in the four lateral toes on the left. Examination showed irregular jerks of flexion in left toes, mvoclonic in appearance. Only mild loss of sensation to touch and pain in left toes. Case 3-Woman aged thirty-six years. Seven years before admission she began to get pain in the back. This was almost constant, and for many years was slight. Some months before admission the pain increased in intensity, and was now confined to the right side only. At the same time she noticed numbness and tingling in the lateral border of the right foot. She had never complained of pain in the legs, and there was no aggravation by straining or coughing. No sphincter disturbances.

I

herniation Operation-The

cells

obtuse

was

months a

disappeared.

Ivelographv

and spine.

on the

puncture

unopened. still

fifth lumbar and first Caudallv a thin second . is seen.

clear,

a rather

to touch

Lumbar

abnormalities

at

strained

of sensation

knee.

lumbar

but

Progress-Four

FIG.

was

laterally

a little

the

the

was made. of the disc,

first

blunting

above

spinal

passed

lying

was

just

abnormality

of

a connection

division.

were

extending

J. RIISHEDE

AND

the fourth lumbar disc was no major herniation

PUlP05U5

disc.

leg,

Radiographs

Operation-There part

Reflexes

left

abnormalities

normal.

nucleus

negative. the

ETHELBERG

she the

sensations lying left

noticed

normal of

the

after and down. buttock.

numbness lordosis

left

foot.

was Left

pain

in the left fifth lumbar Myelography showed a disc. She was thought to herniation of the fourth.

OF

BONE

AND

JOINT

SURGERY

MALFORMATION

OF

LUMBAR

fifth enlargement

Operation-The

appreciable

ROOTS

SPINAL

lumbar lamina of the fifth

AND

was

SHEATHS

displaced

LOW

dorsally

BACKACHE

on

the

AND

left

side,

445

SCIATICA and

there

was

an

canal

foramen. The fifth lumbar and first roots emerged from a common dural sheath (Fig. 4) . This was a little more than twice as as a normal root with coverings. This double sheath coursed caudally to the level of the lumbar intervertebral disc, where it split up in two separate roots. Both roots left the spinal through the fifth lumbar intervertebral foramen. No root was found in the fourth foramen.

The

dura

sacral

thick fifth

left

was

unopened.

Progress-Five There -as

no

raising

questionably

test

The

months stiffness

split

through

vertebral

4-Man aged in a fall. He

recovery

and

attacks

of

before

and and

relieved

by

right

to

the

thigh

lumbar

34 B,

left.

Her

condition

otherwise

Case

passing

of fifth

considerably

through

vertebral

both passing lumbar inter-

is

to

work.

Straight

leg

5

offshoot

which

returned

unchanged.

4-Abnormal

nerve,

had

disorders.

the

foramen

fifth

together

sacral

lumbar

enlarged, lumbar interwith the first

nerve.

heavy

pain

for

Twenty years five hours.

before admission The spine was not

manual

work.

Twelve

sudden

onset,

with

of

became

more

constant

years

before

recovery

and

in

was

now

he

had

sustained

injured.

He

admission a

few

made

he

weeks. worse

by

a

made began

head

a rapid to

have

Eighteen

months

stooping,

jarring,

One year before admission the pain radiated to the back of the right the same time he noticed numbness and weakness of the foot. He was

calf not

manipulations.

lumbar movements and

calf,

lordosis were

with

intervertebral

Operation-No VOL.

decompressed.

FIG.

disc NO.

3,

weakness

1952

and

revealed

no

space, was

was

there There

of dorsiflexion

fifth lumbar and first Reflexes were normal.

disc

protrusion

AUGUST

was obliterated, slightly restricted.

marked

to touch was impaired in the right test was negative on both sides. the right foot. Lumbar puncture of the fifth lumbar intervertebral fourth

satisfactorily

4

pain

straining. toes. At

Exa;nination-The the right. Spinal the

the

were

foramen.

lumbar

admission

coughing and foot

on

forty-nine years. was unconscious

returned

sharp

roots

she had no complaints. She some regression of sensory

dural sheath for first sacral roots, up caudally into

roots, the fifth

separate

Case injury

abnormal

positive

3-Common lumbar and

which

intervertebral

after the operation of the lumbar spine,

FIG. Case fifth

lumbar

IN

and

of the

right

foot

and

toes.

unsteady

with

Radiographs

showed

a slight

spondylosis.

The

scoliosis towards of the muscles in

sacral dermatomes. The gait was

abnormality.

a mild

was a mild lumbar was slight wasting

A diagnosis

Sensation

straight

leg raising dragging

of herniation

of

narrowing

of the

made.

found.

The

fifth

lumbar

spinal

nerve

was

anomalous

both

in

446 its

s. ETHELBERG course

and

it coursed

appearance.

caudally

It left

and

laterally

the

dural

lay

close

it

AND sac

J. RIISHEDE

about

to

the

an

first

inch

more

sacral

caudally

nerve

and

than

passed

normal

and

through

the

as

same

intervertebral foramen. The nerve was enormously thickened (Fig. 5). Along the dorsal surface of the nerve an enlarged tortuous vein was seen. In the cranial part of the field the fourth lumbar nerve was seen passing the third intervertebral disc, but none was found passing the fourth lumbar disc. The first sacral nerve was normal. On palpation no intradural abnormalities were detected, but the dura was not opened. A satisfactory decompression was made. Progress-On discharge he complained of a “ tightening “ in the left foot. The weakness of the foot and sensory disturbances were unchanged. Ten months later he reported that he had no pain, but the dropping of the right foot persisted. He was able to work. Examination showed no stiffness of the lumbar spine. The right foot was dropped and the left ankle jerk diminished. The straight leg raising test was negative. Sensation to touch and pain was impaired on the back of the foot and the great toe on the right. DISCUSSION All

these

patients

indistinguishable intermittent, in the

leg.

were

more

cases

of disc

initial

symptom

should

is usual

us

was

fluid

shown

to

rule

in only only

intervertebral In

on

practice,

it

is

condition

had was

but that

in this

Abnormalities anatomists

of

(Zagnoni

spine

caudally.

develop,

Usually

occupy

the

a slight As

entire

narrowing

of the

compared

with

significant

anomalies

of lumbar

laminectomy

are

less

much

cases

in the

give

are

one

of

because

is low

in this lumbar

so that

may

lumbar

result

that,

been

made of roots

laminectomy. ; in

condition

cauda

one

was

unchanged

equina

was

disclosed-

by

pathologists

frequency

from

changes. the

When

abnormal

diminution

the

roots of this

and

the

cervical

such

changes

and

sheaths

space

by

even

in compression.

intervertebral ; only

has

satisfactorily

the

was

suggest

malformation

described

any

disc

these

department spinal

case

been neurological

roots

work

decreasing

to

space,

disc

results and

in the

with

rise

circumstances.

operation.

it is probably disc

performed than

In

removed.

of herniated

a decompressive

their

previously

intraspinal

herniation

common same

not

nerve

implies

do

after

to occur

intervertebral

of the

work.

improve

said

here,

limited

to

to

is of space

intervertebral

differentiation disc

cases

able

have

are do

correct

although

and

cases

normal

post-operative

adhesion-formation to

reported

and

able

roots

, and they

cases

a

found in

of a lumbar

intervertebral

of no

disc, examination

was

under

it

intervertebral

observed

even

The

in both

was

pulposus

here

is therefore

herniated

of the

is often

and

were

marked

spinal

as

whether

expected

1 949)

as in the

she

be

nucleus

such

in some

reported Furthermore,

Radiographic narrowing

by

examination

cases

puncture and

neurinoma.

of lumbar and

case

cannot

Lumbar considering

upon.

intervention

and

negative.

are

course

followed

Although

in the

so commonly

of herniation

importance

herniation.

was

Marked

operated

complaints

disc

the

neurological

is striking.

osteochondrosis

were

on

histories

long,

eventually

of sensation

spinal

seen,

back,

gave

was

loss

we

diagnosis

surgical no

occurrence

a herniated

was

herniation

improved

worse,

a condition

in which

little

because

patients

or even

of

the

sheaths

history

of the

abnormalities.

of

they

between

sheaths,

no

of lumbar

basis

findings

condition diagnosis.

a pre-operative

this

the

test

correct

case,

that

the

raising

narrowing

and

case

pre-operatively Two

one slight

and

and The

small

develop,

a diagnosis the

disc, each

and

and

out

foot

the

roots disc.

of intervertebral

may

revealed

between

in securing

Otherwise,

in cases

leg

lumbar

in the

however,

changes

straight

cerebro-spinal

value

pain

of the

the

of intervertebral

noted,

similar

that

enables

made,

be

than

prolapse

in differentiation

little

in

the

of dorsiflexion

The it

of herniated

It

is noteworthy value

those

marked

of weakness

malformation

from and

pain

with

four

from

April

neurinomata,

the

cases

frequency were

1943

which

of

found until

were

July

found

clinically

in 1 , 1 62 cases 1951.

They

in twenty-five

period. REFERENCE

ZAGNONI,

della

C. (1949):

Reperto

Societ#{224} Medico-Chirurgica

di

un tipo di

Padova,

non

conosciuto

di

anastomosi

nervosa

delle

radici

spinali.

Atti

27. THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

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