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CARDINAL MANIFESTATIONS OF NEUROLOGIC DISEASE
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Figure 11-5 Lumbar disc herniation on T1-weighted MRI A Sagittal view of large L5-S1 herniated nucleus pulposus (arrow) The extruded material has the same signal characteristics as the normal adjacent disc B Axial view of same disc (arrow) showing the paracentral mass that obliterates the epidural fat signal and compresses the S1 nerve root
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focal or asymmetrical extension of the disc beyond the interspace (protrusion), and in only 1 percent was there more extreme extension of the disc (extrusion) These ndings emphasize the importance of using precise terms in describing the MRI abnormalities and always evaluating these abnormalities in the light of the patient s symptoms Management of Ruptured Lumbar Disc In the treatment of an acute or chronic rupture of a lumbar disc, complete bed rest is usually advised and appears to be helpful, although even this time-honored tenet has been questioned by the results of several randomized studies (Vroomen et al) Nonetheless, we still adhere to this form of treatment, and it is associated with marked improvement in the majority of patients Analgesic medications, either NSAIDs or narcotics, may be required for a few days In a few but not all patients with severe sciatica, we have been impressed with the temporary relief afforded by administration of oral dexamethasone for several days, 4 mg every 8 h, although this has not been studied systematically The only indication for emergency surgery is an acute compression of the cauda equina by massive disc extrusion, causing bilateral sensorimotor loss and sphincteric paralysis or severe unilateral motor loss Although not necessarily the recommended course, it should be pointed out that there are instances where even a dramatic syndrome of cauda equina compression has cleared up after several weeks of bed rest Traction is of little value in lumbar disc disease, and it is best to permit the patient to nd the most comfortable position After a brief period at rest, the patient can be allowed to resume activities gradually, sometimes with the protection of a brace or light spinal support The patient may suffer minor recurrence of the pain but should be able to continue his or her usual activities, and most will eventually recover The more routine measures for man-
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aging back pain, as mentioned in an earlier section, may also be helpful If the pain and neurologic ndings do not subside in response to this type of conservative management or the patient suffers frequent disabling acute episodes, surgical treatment must be considered Most of the patients requiring surgery because of intractable pain within days after a brief trial of bed rest will be found to have a large extruded disc fragment This should be preceded by MRI to localize the lesion (and exclude intra- or extradural tumors); if no lesion is found, CT myelography and EMG may be helpful in detecting lateral recess stenosis and other causes of sciatica (see further on) The surgical procedure most often indicated for lumbar disc disease is a hemilaminectomy, with excision of the disc fragment In cases with sciatic pain due to L4-L5 or L5-S1 disc ruptures, 85 to 90 percent are relieved by operation Rerupture occurs in approximately 5 percent (Shannon and Paul) Arthrodesis (spinal fusion) of the involved segments is indicated only in cases in which there is extraordinary instability, usually related to extensive surgery or to an anatomic abnormality (such as spondylolysis) In our experience and that of our colleagues, the features that are predictive of better outcome from decompressive surgery are younger age, a clear precipitating event for the back and sciatic pain, clinical features that are restricted to compression of a single nerve root, and the absence of chronic or frequently recurrent back pain Issues regarding the use of microscopic surgery and various special techniques are best left to surgical colleagues, but the results are comparable for most techniques The treatment of nerve root compression with repeated epidural injections of methylprednisolone enjoyed a period of popularity, but controlled studies of this procedure have failed to con rm its sustained ef cacy (White et al; Cuckler et al), and the procedure is not without complications Carette et al have found
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