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Patient A, 46-year-old woman, underwent lumbar disc surgery in connection with a radicular syndrome and patient B, a 34-year-old man, underwent laparoscopic cholecystectomy. Both patients suffered postoperatively from dyspnoea, high central venous pressure and an abdominal bruit. Both patients had an initially unrecognised, peroperatively caused, arteriovenous fistula between the common iliac artery and the inferior vena cava. Endovascular therapy was successful. Iatrogenic arteriovenous fistulae are rare and often diagnosed late, partly because in some patients the symptoms may only develop after some delay, partly due to unfamiliarity with this complication on the part of the physician. Doppler ultrasound, CT-scanning and angiography may be used for imaging. Endovascular placement of a covered stent to close the arteriovenous fistula is the treatment of choice.

To determine the mid-long-term outcomes after surgery in patients with lumbosacral radicular syndrome (LRS) and to identify prognostic factors for persisting LRS symptoms.Descriptive retrospective and prospective.A total of 250 consecutive patients operated on by 7 neurosurgeons in four hospitals between May and December 2001 were selected from medical records. They were asked to take part in a telephone questionnaire at 6 and 19 months after operation. They had all undergone discectomy for LRS at L4-L5 or L5-S1 and were aged from 18 to 65.Of the 250 patients, 163 participated in the study: 63% reported that they still had LRS-related symptoms 19 months after surgery. However, severe leg pain had decreased in 83% of the patients. In general the patients were satisfied with their treatment. Female gender and an age of 51-65 were prognostic factors for persistent LRS symptoms.More than half of the patients reported LRS symptoms 19 months after surgery.

Neurogenic muscle (pseudo) hypertrophy of the calf was diagnosed in a 60-year-old man, who presented with chronic, painless and unilateral calf enlargement caused by a chronic S1 radiculopathy due to a lumbar disc hernia in the L5-S1 interspace. The differential diagnosis of a swelling of the calf is extensive. Unilateral painless calf enlargement caused by peripheral nerve disorders is rare and relatively unknown. Neurogenic hypertrophy or pseudohypertrophy of the calf muscles in the context of a chronic S1 radiculopathy has to be included in the differential diagnosis of an unexplained calf enlargement. The underlying pathophysiological mechanism is unclear, but probably includes compensatory hypertrophy, abnormal stretching, and spontaneous electrical activity of denervated muscle fibres.

Two men aged 32 and 39 years had had sciatica for one week and 12 weeks, respectively. In both MRI revealed a prolapsed disc. The first patient recovered spontaneously after 9 weeks, the other recovered after discectomy. After a clinical diagnosis of sciatica, the question arises when additional diagnostic procedures are called for. This question is closely related to the treatment of sciatica. Spontaneous recovery occurs in many patients with sciatica whereas non-invasive therapies including bed rest show a relative lack of effectiveness. While surgical intervention is an effective therapy, the high rate of surgical procedures for disc herniation in the Netherlands compared with most other industrialised countries calls for a critical appraisal of indications for surgery.

Four patients whose most prominent complaint was tingling in the hands are presented. In the first patient, a 33-year-old man, the cause appeared to be a traumatic cervical myelomalacia caused by a rear end collision three years before. The second patient, a 34-year-old woman, initially only had tingling in the hands but eventually developed paresis of the right arm and leg. MRI followed by surgery revealed a centrally located ependymoma. The third patient had a cervical disc protrusion to the left at CVI-CVII. This 49-year-old man recovered after rest and physical therapy. The last patient, a 23-year-old woman, had tingling in the ulnar area of the left hand. This appeared to be caused by an avulsion of the medial epicondyle of the humerus, the result of a trauma 10 years before. After extirpation of the epicondyle the complaints disappeared. In patients with paraesthesias it is very important to take the history meticulously and to perform thorough neurological examination. A simple neuroanatomical scheme may be used to interpret the somatosensory findings.

Lasègue's test is a clinical test to demonstrate lumbosacral radicular irritation. Published evidence gives a high sensitivity (0.80-0.97) for a low lumbar disc protrusion but a low specificity (about 0.4) since this test is also positive in ischialgia due to other causes. A crossed Lasègue test had a high specificity (or = 0.90) for presence of a (ruptured) disc prolapse. There is little or no literature about the reversed Lasègue and provocation by intra-abdominal pressure. The reproducibility of the Lasègue test is moderate (kappa about 0.55).

Three patients, one male aged 81 and two females aged 77 and 81, showed a lumbar disc herniation at CT-scan and caudographic examination. Because conservative treatment was unsuccessful and their premorbid health was good, it was decided to perform an operation. All subjects recovered completely, there were no surgical complications. In patients over the age of 70 showing signs and symptoms of nerve root compression one should consider disc herniation. If this is found, surgery is a reliable option despite advanced age. Pre- operative health state is determinative for the decision whether or not to operate on patients of advanced age.

A 49-year-old man consulted his general practitioner because of left shoulder pain. Analgesics brought no relief. He had a numb feeling in the left axilla. Cervical MRI revealed a herniated disc Cv-Cvi, for which the patient was treated surgically. However, the pain persisted. In retrospect, the axillary numbness could not have been caused by a Cv-Cvi problem, because C6 does not innervate the axilla. Repeated MRI, now of the cervicothoracic region, revealed a tumourous process around TI-TII. Thoracotomy was performed and a mesothelioma was found. The patient died shortly afterwards. It is stressed that the diagnostic satisfaction of a positive MRI finding should not lead to disregarding discrepancies between these radiological results and the clinical findings.

A consensus development meeting concerning the treatment of lumbosacral radicular syndrome (LRS) by entrapment by a herniated disc or spinal stenosis was held on June 9th, 1995. It was observed that there is a lack of good evidence on many aspects of diagnosis and treatment of LRS. Agreement was reached on the thesis that the natural course of LRS is often benign. Diagnosis and treatment can usually be left to the primary care physician. Specialist consultation and ancillary investigations are only needed if an operation is indicated or in case of persistent diagnostic uncertainty. If imaging is needed MRI is preferred to CT or myelography. MRI is highly sensitive, but less specific, and may thus give false-positive results. Neurophysiologic testing may be informative in selected cases. Plain spinal X-rays are not useful in most cases. The traditional non-invasive treatments (such as bedrest, traction, physiotherapy, spinal manipulation) are not based upon convincing scientific evidence. Diagnostic imaging and invasive treatment should be considered in patients with a severe LRS that does not improve within a 4 to 8 week period. Both discectomy and chemonucleolysis are effective treatments. The principal indication is incapacitating radicular pain. There is no sound evidence that the prognosis of paresis is improved by operation. A cauda equina syndrome urgently needs surgical treatment. The efficacy of percutaneous interventions (nucleotomy, laser therapy) has not been proven. There are no strategies for the primary or secondary prevention of LRS that have demonstrated their efficacy. Psychological, social and financial factors probably contribute significantly to the occurrence of persisting symptoms after a LRS. Advice not to work after treatment for LRS may impede rehabilitation.

To measure the variation of chemonucleolysis in the management of lumbosacral intervertebral disk herniation in the Netherlands.Descriptive.Academic Medical Centre, Amsterdam, the Netherlands.The use of chymopapain per specialist from 1987 to 1995 was determined by dividing the amount of chymopapain sold, as given by the pharmaceutical company, by the number of specialists as recorded by the specialist associations. Subsequently, variation of chemonucleolysis in time, between specialists and in place was calculated.Between 1987 and 1995 the number of chemonucleolysis treatments decreased gradually from 2084 to 538. Most neurosurgeons, orthopaedic surgeons and neurologists did not treat patients with herniation of a lumbosacral intervertebral disk with chemonucleolysis. Within the group of specialists which did treat patients with chemonucleolysis, a minority accounted for the majority of treatments. Chemonucleolysis was mainly performed in non-academic hospitals outside urban western Holland.Variation of chemonucleolysis in the management of lumbosacral intervertebral disk herniation in the Netherlands is considerable. Different preferences of specialists are probably the underlying cause.

To determine the prevalence and the burden of diseases of the nervous system in the Netherlands.Descriptive.Institute of Public Health Care, Rotterdam, the Netherlands.Data from medical registrations and statistics concerning diseases of the nervous system from different tiers of health care (general practitioners, hospital, nursing homes) and effects on patient and community (mortality, sickness absenteeism, occupational disablement and costs of illness) were analysed.In general practice, 3-5% of total consultation consisted of neurological diseases (450,000-750,000 cases per year), of which migraine and epilepsy instituted a relatively large group. Of all the hospital admissions, 7% were because of a neurological disease. Neurological disease accounted for 70% of all nursing home admissions. Cerebrovascular accident and hernia nuclei pulposi instituted the largest groups in all sectors. Diseases of the nervous system accounted for 14% of total mortality, 6% of total sickness absenteeism and 14% of total health care costs (f 3.8 billion).Estimating the burden of diseases is difficult because of imperfect medical registration, variations in structure of patient referral and influence of secondary diagnoses. Taking into account the current aging of the population, the prevalence of some neurological diseases, such as CVA, Parkinson's disease and dementia will rise. Priority setting for care and treatment is hampered by differences in burden of illness on the individual and on the community level.

Enlargement of the calf usually is associated with venous thrombosis, haemorrhage, focal myositis or a tumour in bone or muscle. Occasionally a calf enlargement is due to isolated muscle hypertrophy as a sign of radicular or peripheral nerve injury. Most neurogenic muscle hypertrophy is confined to the calf muscle, but the phenomenon has also been seen in other muscles. Three patients with S-I radiculopathy leading to ipsilateral neurogenic calf hypertrophy following hernia nuclei pulposi are described, two men of 79 and 78 years old and a woman of 46 years. The symptoms gradually subsided with time and conservative treatment. The pathogenesis of neurogenic muscle hypertrophy possibly involves partial denervation atrophy and compensatory hypertrophy of remaining muscle fibres.

In the period 1985-1986 twenty-four patients with a recurrent lumbar disk herniation were subjected to surgery in the department of Neurosurgery in the Academic Medical Hospital of Utrecht. In 25% of these patients the second lumbar disk herniation was at the same level and side as the first one. Recurrence of the disk rupture at the same side and level as the first one occurred most often within two years after initial surgery. A recurrent slipped disk at different lumbar level occurred after a time interval of two years or more. Correct diagnosis depends on the results of imaging techniques. All reoperated patients did well after surgery and could return to their work or normal daily obligations.

In order to study the effect of posterolateral spinal fusion on pain and returning to work of patients with chronic lower back pain, a retrospective study was carried out at the University Hospital, Maastricht. Fifty-nine patients with spondylolisthesis I or II, spondylolysis, hemisacralisation, disc degeneration and pseudoarthrosis after spinal fusion were treated by posterolateral spinal fusion. A questionnaire and visual analogue scale were used to assess the pain. The mean preoperative pain level was 8.6; the postoperative pain level was 4.5; 13 patients were without pain. Before operation 41 patients had a job; after operation 34 returned to work. Sex, age, period of complaints, indication or level of operation did not significantly affect the pain score. In particular cases, posterolateral spinal fusion diminishes pain in patients with spondylolisthesis I or II, spondylolysis or hemisacralisation in whom pain does not improve after non-operative therapy. After the operation most patients return to their work.

The influence on practice of a publication about a randomised clinical trial of chemonucleolysis (CNL) vs. herniotomy in patients with lumbar prolapsed intervertebral disc was investigated, using a questionnaire sent to neurosurgeons and neurologists. There were no differences between responses of neurosurgeons and neurologists, nor between academic and non-academic specialists. 63 (57%) of the respondents stated they were not influenced by the paper, 48 (43%) stated they were. 40 of those said they thought more favourably about herniotomy, 8 more favourably about CNL. Opinion about CNL and advice to patients about CNL had no effect on being influenced or not by the article. However, they did modify the direction of influence: both negative and positive opinions about CNL appeared to be reinforced by the publication. Opinion about the best treatment and advice to patients were not fully consistent with each other.

Cervical disc disease is caused by slow or rapid herniation of the intervertebral disc, usually between C2 and C5. The outstanding symptom is pain. Neurological defects are present in approximately 40 per cent of the dogs. Treatment consists of chemotherapy and/or surgery (fenestration or decompression). Fenestration results is gradual resolution of the symptoms, whereas decompression results in rapid resolution. Fenestration has the advantage of preventing future recurrences. The present paper presents a review of the literature, and particular aspects are emphasised on the basis of personal clinical experience.

Results of neurological assessment one year after surgical treatment of herniated lumbar intervertebral disc and lumbar stenosis are reported in 443 patients. Follow-up was performed during one year after operation. Preoperatively, surgeons found motor loss more frequently than patients, (28 and 12% respectively) and, postoperatively, motor loss was still present in 25% and 24%, respectively, of these cases. The operation had caused motor loss in 5% and aggravated motor loss in 3%. Sensibility was reported as abnormal one year after surgery by both patients and surgeons in one-third of the cases. Sensory loss, considered by the patient to have been caused or aggravated by the operation, occurred in 15% of the cases and in 12% of these the surgeons agreed. Preoperatively, unilaterally diminished knee and Achilles tendon reflexes were found in 9% and 42% respectively; one year after surgery, these had recovered in 65% and 57%, respectively. Surgery caused or aggravated unilaterally diminished knee or ankle jerks in 3% and 10%, respectively.

The tolerance of the spinal cord to ionising radiation, particularly the influence of dose and fractionation, is discussed in connection with the medical history of two patients with severe neurological abnormalities, irradiated for breast cancer and Hodgkin's disease. Different forms of radiation myelopathy and the requirements for the diagnostic procedure are described.