Clinical features of conjoined lumbosacral nerve roots versus lumbar intervertebral disc herniations

Unidentified nerve root anomalies, conjoined nerve root (CNR) being the most common, may account for some failed spinal surgical procedures as well as intraoperative neural injury. Previous studies have failed to clinically discern CNR from herniated discs and found their surgical outcomes as being inferior. A comparative study of CNR and disc herniations was undertaken. Between 2002 and 2008, 16 consecutive patients were diagnosed intraoperatively with CNR. These patients were matched 1:2 with 32 patients diagnosed with intervertebral disc herniations. Matching was done according to age (within 5 years), gender and level of pathology. Surgery for patients with CNR or disc herniations consisted of routine microsurgical techniques with microdiscectomy, hemilaminotomy, hemilaminectomy and foraminotomy as indicated. Outcomes were measured using the Oswestry Disability Index and the Short Form-36 Questionnaire. Clinical presentation, imaging studies and surgical outcomes were compared between the groups. Conjoined nerve root’s incidence in this study was 5.8% of microdiscectomies performed. The S1 nerve root was mainly involved (69%), followed by L5 (31%). Patients with CNR tended to present with nerve root claudication (44%) compared to the radiculopathy accompanying disc herniations (75%). Neurologic deficit was less prevalent among patients with CNR. Nerve root tension tests were not helpful in distinguishing between the etiologies. Radiologist’s suspicion threshold for nerve root anomalies was low (0%) and no coronal reconstructions were obtained. The surgeon’s clinical suspicion accurately predicted 40% of the CNRs. Surgical outcomes did not differ between the cohorts regarding the rate of postoperative improvement, but CNR patients showed a trend toward having mildly worse long-term outcomes. Suspecting CNRs preoperatively is beneficial for appropriate treatment and avoiding the risk of intraoperative neural injury. With nerve root claudication and imaging suggestive of a “disc herniation”, the surgeon should be alert to the differential diagnosis of a CNR. Treatment is directed at obtaining adequate decompression by laminectomy and foraminotomy to relieve the lateral recess stenosis. Outcomes can be expected to be similar to routine disc herniations.     

MED治疗腰椎间盘突出症时对神经根变异的探查

目的：观察显微内窥镜下椎间盘切除术（microendoscopic discectomy，MED）治疗腰椎间盘突出症时神经根变异情况，防止出现术中神经根损伤。方法：回顾分析自1999年10月至2003年12月应用MED治疗的腰椎间盘突出症患者724例，其中男452例，女272例。对术中发现存在腰骶神经根变异患者的临床特点及术中所见进行统计分析。结果：724例腰椎间盘突出症患者有37例神经根变异，发生率为5.1％。与术前的临床表现吻合，全部神经根变异患者均在MED下完成手术，无一例出现神经根损伤。结论：仔细探查及分离突出髓核周围神经根发出情况．确定有无神经根变异是防止MED治疗腰椎间盘突出症时发生神经根损伤的重要环节之一。     

青少年腰椎间盘突出症患者下腰椎关节突关节不对称情况分析

目的 :测量青少年腰椎间盘突出症(lumbar disc herniation,LDH)患者下腰椎关节突关节角度,观察其关节突关节不对称(facet tropism,FT)情况。方法:选取2012年8月～2018年8月在我院就诊的LDH和腹部疾病患者。LDH组共纳入52例,其中男42例,女10例,年龄为17.9±1.4岁(14～20岁);L4/5椎间盘突出33例,L5/S1突出18例,L4/5、L5/S1双节段椎间盘突出1例;中央型椎间盘突出24个节段,左侧突出18个节段,右侧突出11个节段。选择腹部CT扫描的层面经过椎间盘且与上位椎体的下终板平行的腹部疾病患者111例作为对照组,其中男87例,女24例,年龄为17.8±1.7岁(14～20岁)。LDH组在腰椎CT片上测量L3-4、L4-5、L5-S1关节突关节角度(作一直线通过椎间盘中点连接棘突基底部中点作为腰椎矢状轴,通过上关节突内外点作一连线,一侧连线与腰椎矢状轴相交所形成的角度即为一侧关节突关节角度),双侧角度之差10°作为FT的衡量标准。对照组在腹部CT片上测量L3-4、L4-5、L5-S1关节突关节角度。结果:LDH组各节段的关节突关节角度的平均值与对照组比较无明显差异(P0.05)。52例LDH患者中,L3-4节段出现FT的患者19例,L4-5节段出现FT 27例,L5-S1节段出现FT 24例;而对照组111例患者中相对应节段出现FT的患者分别为19例、28例、18例,LDH组各节段FT出现的概率明显高于对照组(P0.05)。在LDH组34例L4/5椎间盘突出的患者中,15例出现FT;19例L5/S1椎间盘突出患者中,13例出现FT;椎间盘突出节段FT出现的概率明显高于对照组相应节段(P0.05)。结论:在青少年LDH患者的下腰椎中FT发生率显著高于普通人群,与青少年LDH的发生存在一定的相关性。     

后路显微内镜下下腰段脊神经根鞘膜切开减压术的临床应用(附39例临床报道)

目的探讨后路显微内镜下下腰段脊神经根鞘膜切开减压术的方法及临床效果. 方法选择39例下腰椎间盘突出症术前有严重肢端麻木和剧烈的根性疼痛,术中见神经根明显充血水肿,增粗粘连者.在行髓核切除的同时,采用自制内镜下脊神经根鞘膜切开减压微型手术刀,沿神经根背侧纵行切开3～5 mm. 结果内镜(MED-Ⅱ)下脊神经根鞘膜切开松解39例,17例手术24 h内肢端发麻和根性疼痛症状完全消失,余在术后2周内症状完全消失.该组症状完全消失时间1～14 d,平均6.5 d. 结论微创脊神经根鞘膜切开减压术能迅速缓解腰椎间盘突出症所致患肢肢端麻木和根性疼痛,加快神经功能恢复.内镜下(MED-Ⅱ)腰段脊神经根鞘膜切开减压术是临床上安全有效的方法.     

经皮激光腰椎间盘减压术后腰椎关节突关节和椎间高度的变化

目的：观察经皮激光椎间盘减压术（percutaneous laser disc decompression，PLDD）治疗腰椎间盘突出症术后腰椎关节突关节和椎间高度的变化。方法：应用半导体激光系统对32例腰椎间盘突出症患者进行PLDD治疗。29例患者为单节段突出，其中L3/4 3例，L4／5 18例，L5/S1 8例；3例患者同时合并IA／5和L5/S1节段突出。利用Macnab标准评价随访患者的疗效，并观察术前、术后椎间盘突出节段关节突关节角的形态，测量L3，4、L4/5和L5／S1椎间高度指数和椎间盘突出节段关节突关节角的角度。结果：所有患者无术中和术后并发症。随访14～22个月，平均17个月，按Macnab标准评价：优14例（43．75％），良13例（40．63％）；可3例（9．37％），差2例（6．25％），优良率84．38％。术后L5/S1椎间高度指数与术前相比显著性下降（P〈0．05），但L3/4和L4／5椎间高度指数无显著性改变；关节突关节无明显退变；L4／5和L5／S1椎间盘突出侧的关节突关节角角度显著性下降（P〈0．05），但L3/4椎间盘突出侧的关节突关节角度无显著性改变。结论：经皮激光腰椎间盘减压术后患者的L5／S1椎间高度和腰椎间盘突出侧关节突关节角角度下降．有可能增加腰椎滑脱的风险。     

新型定位板在经椎间孔腰骶神经根封闭术术前定位中的应用

目的 :探讨新型定位板应用在腰椎后外侧经椎间孔腰骶神经根封闭术的术前定位中的有效性、可靠性。方法:2015年3月~2016年3月收治腰椎退行性疾病患者102例,其中单节段腰椎间盘突出症51例,单节段腰椎管狭窄症42例,经皮内窥镜下腰椎间盘切除术后症状复发9例,采用随机数字表随机分入两组后行腰椎后外侧经椎间孔腰骶神经根封闭术。A组54例,手术节段为L3/4 8例、L4/5 28例、L5/S1 18例,采用新型定位板术前定位;B组48例,手术节段为L3/4 8例、L4/5 26例、L5/S1 14例,采用金属定位针术前定位。两组患者年龄、性别、手术节段、保守治疗时间均无统计学差异(P0.05)。记录两组术前的透视次数和准备时间、穿刺时间、穿刺期透视次数、手术并发症、穿刺术后1h穿刺区疼痛VAS评分,并进行统计学分析。结果:A组术前的准备时间为5.2±1.0min、透视次数为1.1±0.3次,穿刺时间9.6±2.2min,穿刺期透视次数3.1±1.0次;B组术前的准备时间为10.7±2.3min、透视次数为3.8±1.2次,穿刺时间16.3±3.3min,穿刺期透视次数4.6±0.6次,两组比较均有统计学差异(P0.05),A组均优于B组。两组均未出现椎管内血肿、腹腔脏器损伤、下肢感觉和运动功能异常,B组出现硬膜刺裂1例(1/48)、穿刺区域皮下血肿4例(4/48),两组并发症发生率无统计学差异(P0.05);术后1h穿刺区域疼痛VAS评分,A组为3.4±0.5分,B组为5.0±0.9分,有统计学差异(P0.05)。结论:对于经椎间孔腰骶神经根封闭术,使用新型定位板术前定位,并进行穿刺路径设计,可减少术前透视次数、术前准备时间,有助于缩短穿刺时间及穿刺期透视次数,定位板具有使用方便、可靠、有效等优点。     

Conjoined lumbosacral nerve roots diagnosis with metrizamide myelography

The most common anomaly of the lumbosacral nerve roots consists of a composite root sleeve containing the roots for two spinal nerves. Before the advent of water-soluble myelography, this anomaly was rarely diagnosed except at operation. Metrizamide myelography readily demonstrates the anomaly because of improved filling of the root sleeves and greater definition of the nerve roots within the subarachnoid space. However, an underlying disk herniation may not be evident on the myelogram because of the unique anatomic configuration.     

退变性腰椎滑脱与关节突关节的方向性

目的：探讨腰椎关节突关节的方向性在退性变腰椎滑脱发生中的病因学意义。方法：34例L4／5退变性腰椎滑脱患者及30名正常对照者的CT扫描片，侧位X线片上关节突关节的方向性及腰椎滑脱程度进行分析。结果：退变性腰椎滑脱患者的关节突关节方向与对照组比较更偏向吴矢状位（P＜0．01），关节突关节不对称程度也更为明显（P＜0．05），小关节椎弓根角更倾向于水平位（P＜0．01），关节突关节角，不对称程度及小关节椎弓根角与腰椎滑脱程度无显著相关性（P＞0．05）。结论：腰椎关节突关节的方向性在退变性腰椎滑脱的发生中可能有一定的病因学意义。     

经皮椎间孔镜技术行腰骶神经根减压松解术治疗腰椎间盘突出症

目的探讨经皮椎间孔镜技术(TESSYS)行腰骶神经根减压松解术治疗腰椎间盘突出症的手术技巧和临床效果。方法回顾性分析自2013-12—2014-10采用TESSYS技术治疗的112例腰椎间盘突出症。术前、术后即刻、术后3个月及末次随访时采用疼痛视觉模拟评分(VAS)评价患者疼痛程度。末次随访时采用改良Macnab评分标准评价临床疗效。结果本组手术时间45~180 min,平均58.6 min;X线曝光频率13~62次,平均18.9次。术中硬膜囊撕裂7例,无神经根损伤、椎间隙感染等严重并发症。102例术后获得随访3~15个月,平均9.8个月。术前VAS评分(7.7±1.6)分,术后即刻(2.8±1.3)分,术后3个月(1.5±0.5)分,末次随访时(1.9±1.5)分。术后即刻VAS评分明显低于术前,差异有统计学意义(t=3.667,P=0.001);术后3个月VAS评分明显低于术后即刻,差异有统计学意义(t=2.862,P=0.001);末次随访与术后3个月VAS评分差异无统计学意义(t=0.033,P=0.120)。末次随访时采用改良Macnab评分评定疗效:优49例,良38例,可15例,优良率85.3%。结论采用TESSYS技术行腰骶神经根减压松解术治疗腰椎间盘突出症是安全有效的微创手术,正确理解和掌握TESSYE技术要点是保证手术成功的关键。     

Synovial cyst of a lumbar facet joint: a rare cause of back pain and sciatica

Summary Intraspinal synovial cysts, sometimes referred to as ganglion cysts, are uncommon lesions which may present as acute or chronic low back pain, with or without radicular symptoms. We present two patients who presented with back pain and radicular symptoms attributable to the unusual pathology of an intraspinal synovial cyst.     

Posterolateral lumbar fusion using facet joint fixation with biodegradable rods: A pilot study

Roentgen stereophotogrammetric analysis (RSA) was used to assess whether there is a potential for biodegradable rods crossing the denuded facet joints to increase the stability and healing rate of lumbar posterolateral fusions. Eleven consecutive patients with lumbosacral disc/facet joint degeneration had a posterolateral fusion augmented with 2- or 3.2-mm biodegradable rods passing perpendicularly through the center of the denuded facet joints. The patients were followed-up with RSA in supine and erect positions monthly from the 2nd to the 6th postoperative month, and again 1 year postoperatively. All seven L5-S 1 fusions healed. Four cases were stable as defined by RSA within 3 months, two within 6 months, and one within 1 year. One L4-S1 fusion could not be evaluated by RSA. None of the remaining three L4-S1 fusions fully healed. In all three cases 1- to 3-mm intervertebral translations remained at 1 year. None of the 11 fusions showed any radiographic signs of osteolysis around the biodegradable rods. The promising results of this pilot study indicate that posterolateral L5-S 1 fusion augmented with transarticular biodegradable rods crossing the denuded facet joints may yield rapid intervertebral stabilization and a high healing rate without any adverse rod effects. This may be due to enhanced initial fusion stabilization and/or increased ossification induced by the rods.     

腰椎后路单节段固定融合术后邻近节段关节突关节退变的随访观察

目的 :分析单节段后路腰椎固定融合(PLIF)术后邻近节段关节突关节(facet joint,FJ)退变的影像学特征,探讨PLIF对融合邻近节段FJ退变的影响。方法:选取2005年1月~2014年1月采用单节段PLIF或单纯髓核摘除术治疗的患者共84例,其中PLIF组(A组)44例,手术邻近节段共140个关节突关节;髓核摘除组(B组)40例,手术邻近节段共122个关节突关节。观察两组患者手术前后病变邻近节段FJ的CT和MRI影像学特征及退变发生率,依据Weishaupt分级系统对FJ进行分级,采用行平均分差检验,对两组患者手术前后病变邻近节段FJ的退变程度进行组内和组间比较。结果:两组患者的性别比、年龄、随访时间及手术节段差异均无统计学意义(P0.05)。FJ退变常见的影像学表现为骨赘形成、关节间隙狭窄、软骨下骨的侵蚀、软骨下囊肿、关节突关节对位不良、关节突关节空气征、关节突关节积液、关节突再塑形以及关节突关节融合。A组术前关节间隙狭窄、软骨下骨的侵蚀发生率分别为52.9%、31.4%,术后为75.7%、62.1%;B组术前关节间隙狭窄、软骨下骨的侵蚀发生率分别为51.6%、30.3%,术后为63.9%、50%。两组患者关节间隙狭窄、软骨下骨的侵蚀术前发生率无统计学差异;术后两组发生率均较术前显著性增加(P0.05),且两组间比较差异有统计学意义(P0.05)。按照Weishaupt分级,A组140个关节突关节中,术前0级3个,1级95个,2级34个,3级8个,退变发生率为97.9%;术后0级1个,1级49个,2级59个,3级31个,退变发生率为99.3%;B组122个关节突关节中,术前0级4个,1级82个,2级30个,3级6个,退变发生率为96.7%;术后0级2个,1级60个,2级39个,3级21个,退变发生率为98.4%,两组手术前后退变发生率差异均无统计学意义(P0.05)。采用行平均分差检验,两组患者组内手术前后对比,术后退变程度加重,与术前比较均有统计学差异(P0.05);两组间比较,A组术前FJ退变程度与B组术前无统计学差异(P0.05);但A组术后FJ退变程度评分较B组术后评分高,差异有统计学意义(P0.05)。结论:腰椎后路单节段固定融合术可能会加速邻近节段关节突关节的退变,以关节间隙狭窄和软骨下骨的侵蚀最为常见。     

腰椎后路单/双节段融合术后上邻近节段关节突关节退变的研究

目的 :研究腰椎后路单/双节段椎间融合术(posterior lumbar interbody fusion,PLIF)后上邻近节段关节突关节(facet joint,FJ)退变的情况,分析上邻近节段FJ退变的影响因素。方法:回顾性分析2009年1月～2015年12月于我院行PLIF的退行性腰椎疾病患者共49例,男27例,女22例,平均年龄55.4±8.6(41～72)岁,随访时间33.0±6.3(25～43)个月,根据融合节段分为L4/5组26例;L4-S1组23例。收集各组患者性别、年龄、随访时间、吸烟史、高血压史、糖尿病史、体重指数(body mass index,BMI)等一般资料,比较术前、末次随访时手术上邻近节段FJ的X线、CT、MRI影像学特征(关节间隙狭窄、软骨下骨侵蚀)、邻近节段椎间隙高度、关节突关节角不对称度,依据Weishaupt分级评估FJ退变特征及退变分级,采用秩和检验对两组患者FJ的退变程度进行组内和组间比较。结果:两组患者性别、年龄、随访时间、吸烟史、高血压史、糖尿病史、BMI等一般资料均无统计学差异(P0.05)。L4/5组术前关节间隙狭窄、软骨下骨侵蚀的发生率分别为51.9%、38.4%;末次随访时发生率分别为73.1%,67.3%。L4-S1组术前发生率分别为67.3%、34.8%;末次随访时发生率分别为97.8%、60.9%。末次随访时,L4/5组邻近FJ重度退变率为52%,L4-S1组为78.2%。术前L4/5组椎间隙高度、关节突角不对称度分别为8.95±0.38mm、7.79°±0.21°;L4-S1组分别为8.65±0.63mm、7.90°±0.09°;末次随访时,L4/5组分别为8.33°±0.51mm、10.43°±0.33°;L4-S1组分别为7.68±0.53mm、12.06°±0.20°,两组间差异有统计学意义(P0.05)。结论:腰椎后路双节段融合固定较单节段更易引起上邻近节段FJ退变,且更容易引起关节突的不对称。     

Parameters influencing the outcome after total disc replacement at the lumbosacral junction. Part 1: misalignment of the vertebrae adjacent to a total disc replacement affects the facet joint and facet capsule forces in a probabilistic finite element analysis

Purpose

After total disc replacement with a ball-and-socket joint, reduced range of motion and progression of facet joint degeneration at the index level have been described. The aim of the study was to test the hypothesis that misalignment of the vertebrae adjacent to the implant reduces range of motion and increases facet joint or capsule tensile forces.

Methods

A probabilistic finite element analysis was performed using a lumbosacral spine model with an artificial disc at level L5/S1. Misalignment of the L5 vertebra, the gap size of the facet joints, the transection of the posterior longitudinal ligament, and the spinal shape were varied. The model was loaded with pure moments.

Results

Misalignment of the L5 vertebra reduced the range of motion up to 2°. A 2-mm displacement of the L5 vertebra in the anterior direction already led to facet joint forces of approximately 240 N. Extension, lateral bending, and axial rotation caused maximum facet joint forces between 280 and 380 N, while flexion caused maximum forces of approximately 200 N. A 2-mm displacement in the posterior direction led to capsule forces of approximately 80 N. Additional moments increased the maximum facet capsule forces to values between 120 and 230 N.

Conclusions

Misalignment of the vertebrae adjacent to an artificial disc strongly increases facet joint or capsule forces. It might, therefore, be an important reason for unsatisfactory clinical results. In an associated clinical study (Part 2), these findings are validated.     

A pure fluid-filled intradural cyst associated with intradural disc herniation and possible pathogenesis: a case report

Background contextLumbar intradural disc herniation (IDH) is rare, and intradural cyst associated with IDH is quite rare. Only seven cases of an intradural cyst associated with lumbar disc herniation have been reported, and all were gas-filled cysts. We report the first case, to our knowledge, of a fluid-filled intradural cyst associated with IDH.PurposeTo report an extremely rare case of a fluid-filled intradural cyst associated with lumbar IDH and suggests the possible pathogenesis.Study designCase report.MethodsAn 82-year-old woman presented with right leg pain and motor weakness. Computed tomography and magnetic resonance imaging (MRI) scans showed calcified lumbar disc herniation and an intradural cystic mass at the L1–L2 level. An MRI, which was performed 2 years before admission, showed an IDH without a cyst at the same level.ResultsSurgical resection of the intradural cyst was performed. Intraoperative finding showed a fluid-filled intradural cyst with 1-cm diameter of displacing nerve rootlets. The cyst was connected with extradural cystic components through a ventral dural hole, but the tract was blocked by fibrous septum. Histopathologic examination showed a pseudocyst that consisted of degenerative cartilaginous and fibrous tissues, including degenerative disc materials. We concluded that the cyst was an intradural cyst transformed from the intradural disc fragment.ConclusionsThe current case is the first report to our knowlege of a fluid-filled intradural cyst associated with IDH. The possible mechanism may be focal degeneration and spontaneous absorption of the intradural disc with fluid production. Unlike the gas-filled intradural cysts, the cause of the pure fluid-filled cyst may be disconnection from the intervertebral vacuum because of a calcified disc and septation of the cyst.     

腰骶神经根畸形的诊断和治疗

目的：通过对11例腰骶神经根畸形患的临床报道。探讨了腰骶神经根畸形的发生率，形态学分型，发病机理，影像学诊断和手术方法。方法：在978例腰椎手术中发现11例腰骶神经根畸形患，4例术前行椎管造影，确诊3例。1例术前行冠状面MRI怀疑神经根畸形。均行全椎板或半椎板切除，上，下关节突切除。根管前彻底减压，并行椎板或横突间植骨融合。结果；全部病例术后随访0．5－8年，平均4．1年，优良率达81．8％。结论：（1）腰骶神经根畸形具有较高的发生率，多发生于L5，S1神经根，（2）腰骶神经根畸形本身并不引起症状；（3）椎管造影和冠状面MRI有助于术前获得确诊；（4）提出术中必须仔细探查神经根，充分显露，彻底减压，并行植骨融合。     

腰椎间盘突出症的椎间盘切除前后神经根血流变化

目的：观察腰椎间盘突出症临床表现与神经根血流变化的关系。方法：应用激光多普勒血流测量仪测量24例病人椎问盘切除手术前后神经根血流的变化，分析其相关因素。结果：术后下肢痛早期缓解病人神经根血灌流量增加明显高于延期缓解病人，神经功能障碍早期恢复病人神经根血灌流量增加明显高于延期恢复病人，破裂型病人较未破裂型病人术后神经根血灌流量增加明显。结论：术后早期坐骨神经痛缓解和神经功能障碍恢复是间盘切除术后神经根血运恢复的结果，机械性压迫导致的神经根缺血是坐骨神经痛和神经功能障碍的根本原因。     

Congenital absence of lumbosacral articular process: report of three cases.

Defective anomaly of the articular process of the lumbosacral region in three young women is reported. One had a bilateral defect at the lower facet of L1 with defect at L5 right lower and S1 right upper facets. Another had bilateral defects at L5 lower facets, and the third had a defect at the left lower facet of L5 with other anomalies of the lamina. Based on classification of 37 anomalies including those previously reported in the literature, it is concluded that unilateral defect at the lumbosacral apophyseal joint involving both upper and lower facets is the most common anomaly. The pathogenesis of all anomalies is apparently complex. The intervertebral instability caused by these defects may provoke occasional low-back pain, especially in younger persons with a unilateral L5/S1 anomaly.     

Sacroiliac joint dysfunction in patients with imaging-proven lumbar disc herniation

A dysfunction of a joint is defined as a reversible functional restriction of motion presenting with hypomobility according to manual medicine terminology. The aim of our study was to evaluate the frequency and significance of sacroiliac joint (SIJ) dysfunction in patients with low back pain and sciatica and imaging-proven disc herniation. We examined the SIJs of 150 patients with low back pain and sciatica; all of these patients had herniated lumbar disks, but none of them had sensory or motor losses. Forty-six patients, hereinafter referred to as group A, were diagnosed with dysfunction of the SIJ. The remaining 104 patients, hereinafter referred to as group B, had no SIJ dysfunction. Dysfunctions were resolved with mobilizing and manipulative techniques of manual medicine. Regardless of SIJ findings, all patients received intensive physiotherapy throughout a 3-week hospitalisation. At the 3 weeks follow-up, 34 patients of group A (73.9%) reported an improvement of lumbar and ischiadic pain, 5 patients were pain free. Improvement was recorded in 57 of the group B patients (54.8%); however, nobody in group B was free of symptoms. We conclude that in the presence of lumbar and ischiadic symptoms our presented data suggest consideration of SIJ dysfunction, requiring manual medicine examination and, in the presence of SIJ dysfunction, appropriate therapy, regardless of intervertebral disc pathomorphology. This could avoid wrong indications for nucleotomy. Received: 27 November 1996 Revised: 10 June 1998 Accepted: 13 July 1998