Elevated cerebrospinal fluid proteins in sciatica caused by disc herniation

Cerebrospinal fluid protein concentration in patients with lumbar spinal stenosis

Background

In this study, we examined the impact and degree of lumbar stenosis on cerebrospinal fluid (CSF) protein concentration.

Methods

In this retrospective study, we analyzed protein concentrations in CSF samples of 61 patients with lumbar spinal stenosis (LSS) obtained during pre-operative myelography. Patients were divided into two groups: those showing no block to contrast (Group A) versus those showing medium block to contrast below the lumbar puncture level (Group B).

Results

The CSF protein concentration in Group B (104.3 ± 59 g/dL) patients with medium block was significantly greater than that in Group A (65.1 ± 33 g/dL) patients without medium block.

Conclusion

A higher average CSF protein concentration was seen in Group B patients with significant lumbar stenosis versus Group A patients without significant lumbar stenosis. Theoretically, damage to the cauda equina in patients with LSS may cause these elevated CSF protein levels.

Rheumatic presentations of Guillain-Barré syndrome as a diagnostic challenge: A case series

BACKGROUND

Guillain-Barré syndrome (GBS) is an immune-mediated acute polyradiculoneuritis often in post-infectious context. It is a therapeutic emergency as early treatment may prevent disabilities. Pain in GBS has been described extensively, may precede neurological symptoms and bring the patient to rheumatology departments in the first place.

OBJECTIVE

To describe the clinical presentations and diagnosis of GBS cases referred to rheumatology departments.

METHOD

For this retrospective case-series, we screened patients of the rheumatology department (university hospitals of Strasbourg), whose hospitalization records were associated with the ICD-10 Code G61.0 (GBS) from 1993 to 2020. We included patients fulfilling the 1990 NINDS criteria and level one of the Brighton collaboration criteria. We measured the time from symptoms onset to admission and from admission to lumbar puncture as a marker of outpatient and inpatient diagnosis delay, respectively.

RESULTS

We describe 8 GBS cases. Six had nociceptive-like prodromal pain: back pain (n=3), peripheral arthralgia (n=1) or diffuse myalgia (n=3). The median time from symptoms onset to admission was 7days [range: 3-60] and the median time from admission to lumbar puncture was 2days [range: 0-8]. Two patients became severely tetraparetic, one requiring intubation. At last follow-up (median: 5.5years; range: 0.5-23years), 4 patients had recovered completely and 4 kept disabilities.

CONCLUSIONS

Rheumatic presentations of GBS are rare and diverse. Rheumatologists should be aware of this presentation because early diagnosis and treatment may prevent rapid motor worsening. Rapidly progressive symmetric weakness and areflexia appear as the best clinical diagnosis markers.

High-resolution nuclear magnetic resonance spectroscopic study of metabolites in the cerebrospinal fluid of patients with cervical myelopathy and lumbar radiculopathy

There have been few reports describing substances related to oxidative and intermediary metabolism in the cerebrospinal fluid (CSF) in patients with spinal degenerative disorders. This study investigated whether the concentrations of metabolites in the CSF differed between patients with spinal degenerative disorders and controls, and whether the concentrations of these metabolites correlated with the severity of symptoms. CSF samples were obtained from 30 patients with cervical myelopathy (Group M), 30 patients with lumbar radiculopathy (Group R), and 10 volunteers (control). Metabolites in these CSF samples were measured by nuclear magnetic resonance spectroscopy. There were no differences in the concentrations of lactate, alanine, acetate, glutamate, pyruvate, or citrate between Groups M and R, between Group M and the control, or between Group R and the control. In Group M, neither symptom duration nor the Japanese Orthopaedic Association score correlated with the concentration of any metabolite. In Group R, the symptom duration positively correlated with the concentration of lactate, glutamate, and citrate in CSF. The duration of nerve root block showed a negative correlation with the concentrations of acetate in CSF of the patients in Group R. In patients with lumbar radiculopathy, there is a possibility of increased aerobic metabolic activity or decreased gluconeogenic activity in patients with shorter symptom duration, and increased aerobic metabolic activity in patients with severe inflammation around a nerve root.

Tumor necrosis factor-alpha, interleukin-1beta, and interleukin-6 in the cerebrospinal fluid of patients with cervical myelopathy and lumbar radiculopathy

There have been few reports describing cytokines in the cerebrospinal fluid (CSF) of patients with spinal degenerative disorders. This study investigated whether interleukin-1beta (IL-1beta), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha) could be detected in CSF of patients with cervical myelopathy or lumbar radiculopathy and whether the concentrations of those cytokines correlated with the severity of disease conditions. CSF samples were obtained from 21 patients with cervical myelopathy (Group M) and 19 patients with lumbar radiculopathy (Group R), and six volunteers (control). The concentration of IL-6 was significantly higher in Groups M and R than in the control, possibly demonstrating spinal cord and nerve root damage, respectively. However, TNF-alpha was lower than the detection limit. IL-1beta was detected in only five samples from three patients in Group M and two volunteers in the control. The concentrations of IL-6 did not show any correlation with symptom duration, the scoring system by the Japanese Orthopaedic Association, or the duration of nerve root block. There is a possibility that the concentration of inflammatory cytokines in CSF can indicate certain pathological aspects of cervical myelopathy or lumbar radiculopathy.

Proteomic analysis of the cerebrospinal fluid of patients with lumbar disk herniation

To better understand the pathophysiologic mechanisms underlying spinal nerve root injury induced by lumbar disk herniation (LDH), comparative proteomic analysis of cerebrospinal fluid (CSF) between patients with LDH (the experiment group) and the otherwise healthy patients who had had implants removed from healed fractures in the lower limbs (the control group) was carried out using 2-DE followed by LC-IT-MS and database searching. Image analysis of silver-stained 2-DE gels revealed that 15 protein spots showed significant differential expression between the two groups of CSF samples (p < 0.05). After searching the database we found that in CSF of LDH patients, the expression of cystatin C, apolipoprotein A-IV, vitamin D-binding protein, neurofilament triplet L protein, IgG, tetranectin, and hemoglobin were elevated. However, ProSAAS, prostagladin D2 synthase, creatine kinase B, superoxide dismutase 1 and peroxiredoxin 2 were decreased. The subsequent ELISA measured the concentration of tetranectin, vitamin D-binding protein and cystatin C and confirmed the results of proteomic analysis. These identified proteins are involved in the pathophysiological process of spinal nerve root injury caused by herniated lumbar disk. The functional implications of the alterations in the levels of these proteins are discussed in this paper.

Effect of bupivacaine application on cholinesterase activities, total protein- and albumin concentration in serum and cerebrospinal fluid

The rationale of this study was to determine whether Bupivacaine used for spinal anesthesia alters the specific secretory activity of nerve cells and/or the function of the blood/cerebrospinal fluid barrier. Four groups were assessed: (1) patients undergoing spinal anesthesia using Bupivacaine for lower limb surgery, (2) spinal Bupivacaine anesthesia without subsequent surgery, (3) local facet joint infiltration using Bupivacaine, and (4) general anesthesia for lower limb surgery without Bupivacaine application. Cholinesterase activities, total protein- and albumin concentrations in serum as well as in cerebrospinal fluid were significantly decreased after surgical intervention under spinal Bupivacaine anesthesia but remained unchanged following spinal Bupivacaine application without surgery. No significant correlation was found between Bupivacaine dosage and parameter alteration. There was no influence of intrathecal Bupivacaine application on the albumin ratio cerebrospinal fluid/serum, nor was there any significant alteration of total protein- or albumin concentrations and butyrylcholinesterase activity in the serum as a result of local injection of Bupivacaine to facet joints. These serum parameters were reduced after surgery under general anesthesia. Alterations of serum- and cerebrospinal fluid parameters investigated after surgery are not related to Bupivacaine application but to effects linked to operative treatment, i.e. suppressed secretory cell activity or protein depletion owing to blood loss. We conclude that the secretory function of cholinesterase-releasing nerve cells is not affected by spinal application of Bupivacaine. The blood/cerebrospinal fluid barrier remains intact.

Nerve root injuries in patients with chronic low back pain

In conclusion, the nerve roots and the DRG play an important role in the pain mechanisms of patients suffering from chronic low back pain. Signs of demyelination and increased sensitization for stimuli occurs after a direct nerve root trauma, and the plasticity for the DRG also may change the response to a given peripheral stimuli when repeated frequently over a long period of time. The regeneration mechanisms of spinal nerve roots and DRG regarding function are slow, and the final grade of recurrence depends on the degree of injury. The limited regeneration mechanisms for nerve injury and the fact that "established chronic pain centers" are hard to influence after a long pain history favor an aggressive strategy for pain management. Today, a number of treatment strategies exist for chronic low back pain patients (with or without a diagnosed nerve root injury). These strategies include physiotherapy, nonsteroid anti-inflammatory drugs (NSAIDs), steroids, analgesics of different types and administration routes, surgery, and other sorts of invasive treatments. Further knowledge about the nerve root, DRG, and the rest of the nervous system in these patients is necessary; for understanding how and when to treat patients with chronic low back pain, we need to understand more about what we are trying to treat.

Glycosphingolipid antibodies in serum in patients with sciatica

STUDY DESIGN

Serum antibody titers against 10 different glycosphingolipids were investigated by enzyme-linked immunosorbent assay in three groups of patients: patients with acute sciatica (Group IA, radicular pain for 32 +/- 36 days, n = 68), a subgroup of these patients 4 years later (Group IB, n = 23), and patients undergoing lumbar discectomy because of disc herniation (Group II, n = 37).

OBJECTIVES

To investigate the immunologic response in sciatica patients by analyzing circulating autoantibodies against glycosphingolipids, molecules highly expressed in cells from the nervous system, and the possible correlation of such antibodies to clinical and imaging findings as well as to subjective symptoms.

SUMMARY OF BACKGROUND DATA

The titers of glycosphingolipid antibodies are elevated in neurologic diseases with autoimmune stimulation such as Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy.

METHODS

Antiglycosphingolipid antibodies were assayed by a microtiter enzyme-linked immunosorbent assay method. Antibody titers were related to a healthy population by a method that judges all positive results (positive result = patient sera/pooled blood donor serum >2, at titer 1/400) as indicating a pathologic condition.

RESULTS

Increased levels of circulating antibodies against one or more glycosphingolipids were detected in 71% of patients with acute sciatica, in 61% of sciatica patients at a 4-year follow-up visit (eight antigens analyzed) and in 54% in patients undergoing discectomy. These frequencies were somewhat higher than, and in the last group similar to, those reported for generalized nervous system disorders with autoimmune involvement. In the acute sciatica patients, positive neurologic findings were associated with increased levels of two of the examined antibodies: 3'LM1 (immunoglobulin M and/or immunoglobulin G), P = 0.023, and GD1a (immunoglobulin M), P = 0.017.

CONCLUSION

The presence of glycosphingolipid antibodies in patients with sciatica and disc herniation suggests an activation of the immune system and thus a process possibly involved in the pathophysiology of sciatica. The autoimmune response was not limited to antibodies against one specific glycosphingolipid target; rather, an overall increase in autoantibodies against nervous system-associated glycosphingolipids was observed. These results encourage further studies of the pathophysiologic and clinical relevance of autoimmune responses in patients with sciatica and disc herniation.

Protein markers in cerebrospinal fluid in experimental nerve root injury. A study of slow-onset chronic compression effects or the biochemical effects of nucleus pulposus on sacral nerve roots

STUDY DESIGN

Measurement of changes in cerebrospinal fluid concentrations of nerve tissue markers, total proteins, and immunoglobulin after compression of nerve root or application of nucleus pulposus in a pig model.

OBJECTIVES

To assess whether compression or application of nucleus pulposus to spinal nerve roots may cause increased levels of cerebrospinal fluid markers of nerve tissue damage and total proteins, and whether synthesis of immunoglobulins may be induced in cerebrospinal fluid.

SUMMARY OF BACKGROUND DATA

Previous studies have reported that there seems to be a relationship between elevated cerebrospinal fluid total protein concentrations, nerve tissue markers, clinical findings, and compression of the nerve root evaluated by radiologic changes in patients with sciatica.

METHODS

Subjects included 41 pigs, including 5 control animals. In two groups of experimental animals (n = 7; n = 5), an ameroid constrictor was slid onto the S1 nerve root. In two other groups (n = 7; n = 5), nucleus pulposus harvested from the L2-L3 disc was applied to the S1 nerve root. Two sham animal groups (n = 7; n = 5) underwent the same laminectomy. Twenty-one pigs underwent reoperation after 1 week, and 15 pigs after 4 weeks. A syringe was used to remove 3 mL of cerebrospinal fluid at L4-L5. Concentrations of total proteins, the light subunit of the neurofilament protein, S-100 protein, neuron-specific enolase, and glial fibrillary acidic protein were measured, and the presence of oligoclonal bands (immunoglobulins) were assayed in cerebrospinal fluid.

RESULTS

The pigs with compressed S1 nerve root had considerably higher neurofilament protein and total protein concentrations in their cerebrospinal fluid than the-control animals (P < 0.001 and P < 0.01, respectively) or the sham animals (P < 0.001 and P < 0.05) in the 1-week experiment. Nucleus pulposus did not induce a significant increase in concentrations of the different protein markers. The presence of oligoclonal bands in cerebrospinal fluid in the experimental groups did not differ between the control and sham animals.

CONCLUSIONS

The neurofilament protein and total protein concentrations in cerebrospinal fluid may have diagnostic importance in cases wherein clinical findings are not clearly related to the radiologic changes and vice versa. These protein markers also may be useful tools in different experimental models.

Markers of nerve tissue injury in the cerebrospinal fluid in patients with lumbar disc herniation and sciatica

STUDY DESIGN

The light subunit of neurofilament protein, S-100 protein, neuron-specific enolase, and glial fibrillary acidic protein were determined in the cerebrospinal fluid in patients with lumbar disc herniation and in control patients.

OBJECTIVES

To determine whether nerve root injury caused by disc herniation increases the levels of nerve and glial cell injury markers in the cerebrospinal fluid.

SUMMARY OF BACKGROUND DATA

Markers of nerve tissue injury can be analyzed in the cerebrospinal fluid, allowing characterization of the cell types involved and the degree of disease in patients with neurologic disorders.

METHODS

Cerebrospinal fluid samples were obtained by preoperative lumbar puncture in patients who underwent surgery for lumbar disc herniation and in patients who underwent lower extremity surgery (control group), neurofilament protein (light subunit) and glial fibrillary acidic protein were analyzed by enzyme-linked immunosorbent assay and S-100 protein and neuron-specific enolase by radioimmunoassay and luminescence immunoassay, respectively. In the disc herniation group the concentrations of the four markers were evaluated regarding possible correlation to patient history, computed tomographic findings, and clinical findings.

RESULTS

Cerebrospinal fluid concentration of neurofilament protein (light subunit) and S-100 were increased in the disc herniation group compared with that in control subjects (1158 +/- 383 ng/L vs. 152 +/- 14 ng/L, P < 0.01; 1963 +/- 231 ng/L vs. 1003 +/- 152 ng/L, P < 0.05, respectively). No statistical differences in neuron-specific enolase and glial fibrillary acidic protein concentrations were observed between the groups. Disc herniation patients with fewer than 3 months' duration of subjective symptoms had higher neurofilament protein levels than did patients with longer duration. None of the markers was related to preoperative clinical or computed tomographic findings. Patients with persistent neurologic findings at follow-up 2-3 months after surgery had higher levels of neurofilament protein before surgery compared with-those without sequelae.

CONCLUSIONS

Patients with disc herniation and sciatica have increased concentrations of neurofilament protein and S-100 in the cerebrospinal fluid, which indicates damage of axons and Schwann cells in the affected nerve root.

Higher levels of antibodies against the psoriasis-associated antigen pso p27 in cerebrospinal fluid from patients with low back pain and sciatica

STUDY DESIGN

A prospective study comparing the presence of antibodies against the psoriasis-associated antigen pso p27 in pain-free control subjects and patients with low back pain and/or sciatica.

OBJECTIVES

To analyze the amount of local inflammation present in human lumbar disc disorders, using anti-pso p27 antibodies in the cerebrospinal fluid as a marker and to analyze whether pain intensity correlates with this marker of inflammation.

SUMMARY OF BACKGROUND DATA

Pso p27 is a major antigen in psoriasis that is also present, mostly locally, in other inflammatory disorders, such as sarcoidosis, inflammatory bowel disease, and ankylosing spondylitis, inflammation is also thought to play a major role in the generation of lumbar and radicular pain in degenerative disc disorders.

METHODS

Anti-pso p27 antibodies in cerebrospinal fluid were quantified using an indirect enzyme-linked immunosorbent assay with pso p27 obtained from patients with psoriasis for use as an antigen. Fifteen patients with spinal stenosis, 11 patients without myelographic disc herniation, 17 patients with disc herniation, and 24 pain-free patient control subjects were studied.

RESULTS

Significantly higher levels of anti-pso p27 antibodies were found in patients with myelographic signs of disc herniation than in with patients with no signs of herniation, patients with spinal stenosis, and control subjects. Patients with no known signs of disc herniation and patients with myelographic signs of spinal stenosis (< 10 mm in diameter) caused by degenerative changes, had higher levels of anti-pso p27 antibodies than did control subjects. However, these differences reached only borderline statistical significance.

CONCLUSIONS

The results support those in previous reports, that inflammation probably plays an important role in degenerative disk disorders, particularly in disk herniations. That there was no correlation between pain intensity and anti-pso p27 activity indicates that the antigen is probably not essential in pain generation per se. The results may indicate that pso p27 is expressed secondary to, not as an initiator of, inflammation.