Rheumatology 2001; 40: 1427-1428
© 2001 British Society for Rheumatology
Letters to the Editor |
Lumbar scoliosis associated with a disc herniation in an adult
Department of Orthopaedic Surgery, University Hospitals of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
SIR, Sciatic scoliosis as a presenting feature of lumbar disc herniation is uncommon, particularly in adults, although several cases have been reported in adolescents [1, 2]. We describe a female adult who presented with a significant lumbar scoliosis secondary to an L4/5 disc herniation.
A 39-yr-old female presented with back and left leg pain and a bizarre scoliosis. Her back pain had been intermittent for the previous 2 yr and after 1 yr she had started to develop a deformity. She had experienced intermittent episodes of pins and needles and weakness in her left leg, but no bowel or bladder disturbance. She had previously been treated with a variety of conservative measures without response. She had not been able to work or to participate in her main hobby of aerobics for the previous 12 months.
On examination, she displayed an obvious deformity causing her to tilt to the right. There was localized tenderness in her lower lumbar spine associated with muscle spasm, producing restriction of lateral flexion, particularly to the left. Straight leg raising on the left was limited to 25° by leg pain. Neurological examination of her lower limbs was otherwise normal. Plain X-rays confirmed the deformity as a simple lumbar scoliosis with a Cobb angle of 40°. An MRI scan showed a modest-sized left L4/5 disc herniation medial to the nerve root. She underwent a routine mini-discectomy. Within 24 h of surgery, her leg pain had almost completely resolved and her left straight leg raise had improved to 70° without signs of root tension. Three weeks later her posture had improved considerably, and by 2 months after surgery her posture had almost returned to normal (Fig. 1
). At her final review at 6 months, she complained of only minor back pain and had returned to work and restarted aerobics.
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This patient had been suffering with low back pain intermittently for a year before she developed any postural deformity, which appeared when her symptoms worsened with the development of left sciatica. The development of scoliosis following progression of low back pain to sciatica is recognized [3]. Duncan and Hoen [4] studied the association between sciatic scoliosis and lumbar disc herniation. They found that if the lesion is located laterally in the disc space, then the list occurs to the contralateral side. They consequently inferred that a central protrusion would result in a flat back or kyphosis. Finneson [5] reported that if the protrusion is lateral to the nerve root, then the patient will lean away from the lesion, whereas if the protrusion is medial to the root the list will be towards the lesion. Matsui et al. [6] observed that patients with lumbar disc herniation and sciatic scoliosis tended to list to the side opposite to the sciatica, producing convexity towards the side of the sciatica. Our patient had a left lumbar disc herniation medial to the nerve root, but the scoliosis was to the right.
While it is quite unusual for any prolapsed disc, causing sciatica in an adult, to present with gross scoliosis, we consider this case to be especially unusual in view of the relatively modest size of the protrusion. However, we were unable to find any published studies relating the severity of pain to the size of the disc protrusion, although we are aware of imaging studies in which disc protrusions have been identified in asymptomatic individuals [7]. Furthermore, we now have more knowledge about the biochemical basis of radiculopathy, whereby pain may be associated with local inflammatory mediators associated with disc degeneration [8].
Whilst this theory may explain the severity of her pain, it does not necessarily explain why she developed such a bizarre deformity. Preoperatively, the patient appeared considerably disabled, with a high Oswestry Disability Index (64). However, her Modified Zung Depression Index (MZDI) was also high (47), indicating an element of distress, and it is possible that this influenced her overall presentation. Six months after surgery, however, her MZDI had declined to 10 and she had returned to normal function, including employment, having been unable to work for 14 months. She had never been considered for psychological counselling and there were no obvious psychosocial issues apparent in her presentation. Although we had decided on a surgical approach, it is possible that her disability might also have responded to the approach offered by a functional rehabilitation programme. However, the fact that she made an excellent recovery after surgery demonstrates that where disability and distress present together, both can resolve if any associated underlying organic pathology is addressed.
Notes
Correspondence to: M. L. Newey. 
References
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- Finneson BE. Low back pain. Philadelphia: J. B. Lippincott, 1973; 290–03.
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