Causes of Persistent Pain after Lumbar Discectomy

(A) MR Neurography demonstrates flattening of the exiting nerve root (**) by a persistent fragment of disc material (fr) in the foramen. The contralateral nerve root (*) has a normal caliber.  

(B) 36-year-old man with right S1 dysesthetic pain after microdiscectomy. Post-operative imaging showed good decompression, but the Neurography demonstrated persistent hyperintensity of the dorsal root ganglion (DRG) consistent with intraoperative mechanical trauma.  No further surgical treatment was recommended.

Use of MR Neurography for Diagnosis of Routine and Unusual Spinal Pathologies

Animation: Adiculopathy exacerbated by lumbar spine instrumented fusion.

(A) 59-year-old woman with persistent severe left  S1 radiculopathy exacerbated by lumbar spine instrumented fusion and not relieved by subsequent removal of the instrumentation. The image demonstrates perforation of the left S1 root by the course of the pedicle screw (ps). No further surgical treatment was recommended.

(B) Persistent sciatica after a fall with no improvement after discectomy. The image demonstrates inflammation around the nerve (S1) consistent with a sacral fracture (fx) abutting the foramen.

(C) The MR Neurography imaging protocol results in an MR myelogram as well as Neurographic images of the exiting nerve roots.

Post-Discectomy Nerve Root Inflammation

Animation: Post-discectomy radiculitis.

Two fascicles in the right S1 root are hyperintense as they descend from the root sleeve (A) and traverse the sacrum (B,C, D & E  arrows).

The contralateral S1 root is normal in appearance. The patient experienced focal pain in the calf despite relief of other symptoms by microdiscectomy. There was no recurrent disc.

The symptoms resolved with a short course of dexamethasone.

Image Effects of Bone Spur Affecting the Spinal Root

Animation: CT/MR pair of images in patient wih hyperintensity and a bone spur.

(A) hyperintensity in a portion of the dorsal root ganglion (*) on MRI and

(B) a bone spur (**) on the corresponding bone CT images that physically contacts the site of hyperintensity in the ganglion. Taken together the images demonstrates that a surgically treatable small bone spur is probably responsible for the persistent symptoms.

(C) The MR myelogram shows hyperintensity in the root.

(D) The absence of filling in the X-ray myelogram confirms that the brightness is attributable to hyperintensity rather than to the presence of CSF.

Foraminal Impingement after Disk Surgery

Animation: Complete S1 spinal root and spinal nerve image demonstrating proximal right sided pathology and distal left sided pathology.

This case involves a 66-year-old woman with bilateral radicular symptoms and non-diagnostic lumbar MRI who did not improve after two decompressive lumbar spine surgeries.

(A) Anterior image plane demonstrated distal right S1 foraminal impingement with hyperintensity in the nerve root seen in A (*) and in B (**).

(B) Posterior image plane (3mm slices, no spacing) confirms hyperintensity in distal S1 root. The right proximal sciatic nerve is broadened and flattened at the sciatic notch with mild edema and increased caliber of fascicles. Her physical exam was consistent with a piriformis syndrome on the left only.

Distal Foraminal Impingement - Additional Case

Animation: MR Neurographic image of exiting lumbar spinal nerve in foramen.

(A) Normal configuration showing the exiting spinal root as seen in routine myelogram, but also showing the configuration of the dorsal root ganglion and the proximal spinal nerve in the distal foramen which is not well seen in other imaging techniques.

(B) 74-year-old man with degenerative scoliosis and L4 radiculopathy. Myelography showed no evidence of nerve root cutoffs. The MR Neurography image demonstrated a severe stenosis in the distal foramen. His symptoms resolved with distal foraminotomy.

Distal Foraminal Impingement

Animation: Lumbar neurography for evaluation of sciatica of non-disc origin. Distal foraminal lumbar nerve root entrapment.

(A) Normal anatomy of the L3, L4 and proximal L5 nerve roots and lumbar spinal nerves as they exit the spine traveling in essentially linear fashion.

(B) Exiting right L5 nerve root (*) of 65-year-old woman with persistent right L5 radiculopathy after two spine surgeries. The course of the exiting root is distorted; there exists both focal narrowing and a region of hyperintensity (n).

(C) Myelogram of same patient obtained just prior to MR Neurography. The L5 root abnormality is too distal to be appreciated in the myelogram (*) and the study was read as showing a normal L5 root with no impingement. After the Neurographic diagnosis, the patient had a distal foraminotomy with excellent lasting relief of her radiculopathy.

Complex Spine Surgery

Modern treatment for degenerative spine disease, spine tumors, infections, spine fractures and instabilities is considered to be complex spine surgery. Surgical treatment for these conditions may include minimally invasive microsurgical anterior and posterior approaches to the entire spine and often require fusion with titanium devices, bone grafts, pedicle screws, plates and rods.

With the use of the advantageous Stealth neuronavigation system surgeons  are able to place titanium instrumentation devices with unparalleled accuracy.

This revolutionary technology and surgical skill offers patients faster recovery and minimizes postoperative pain and complications.

Minimal Access Spinal Technologies

When spine problems develop due to injury, aging, wear and tear, or deformity, treatment options should focus on the actual source of the problem with the least amount of interruption to a patients life. Medication, physical therapy, bracing or lifestyle changes may successfully treat problems caused by slipped discs, slipped vertebrae or curvature of the spine. For many people, though, surgery may be the best option to treat pain or deformity.