Case report Sciatica, disk herniation, and neuroborreliosis. A report of four cases Arnaud Dupeyron a, *, Jehan Lecocq a , Benoît Jaulhac b , Marie-Eve Isner-Horobeti a , Philippe Vautravers a , Julien Cohen-Solal c , Christelle Sordet c , Jean-Louis Kuntz c a Physical Medicine and Rehabilitation Unit, Strasbourg Teaching Hospitals,Avenue Molière, 67098 Strasbourg cedex, France b School of Medicine, Bacteriology Institute, Louis Pasteur University and Strasbourg Teaching Hospitals, 67000 Strasbourg, France c Rheumatology and Clinical Immunology Department, Strasbourg Teaching Hospitals,Avenue Molière, 67098 Strasbourg cedex, France Available online 25 September 2003 Abstract We report four cases of sciatica in patients with same-level disk herniation confirmed by computed tomography and a final diagnosis of acute radiculitis caused by Borrelia burgdorferi, with a favorable response to ceftriaxone therapy. The neurological manifestations of Lyme disease are protean, and a potential contribution of concomitant disk disease to sciatica can lead to diagnostic wanderings. Disk lesions and infectious conditions that can cause sciatica are discussed. Whether a favorable response to antibiotic therapy should be taken as proof of B. burgdorferi radiculitis deserves discussion. In practice, in a patient with clinical manifestations suggesting disk-related nerve root pain and residing or having traveled to an endemic area, B. burgdorferi infection should be looked for, as both etiologies can coexist. © 2003 Elsevier SAS. All rights reserved. Keywords: Neuroborreliosis; Sciatica; Disk herniation; Meningoradiculitis 1. Introduction The neurological manifestations of Lyme disease, a con- dition caused by the spirochete Borrelia burgdorferi, are protean, the most common in Europe being meningoradicu- litis. The considerable diversity of the peripheral neuropa- thies caused by B. burgdorferi raises major diagnostic chal- lenges. We report four cases of sciatica with same-site disk herniation confirmed by computed tomography, in which failure of appropriate medical treatment led to a reappraisal of the diagnosis. Evidence of neuroborreliosis was found, and antibiotic therapy was effective. The disk herniation may have been a mere coincidence that played no role in the genesis of the nerve root pain. Alternatively, the disk hernia- tion and neuroborreliosis may have interacted to cause the sciatica, perhaps via mutual potentiation or perpetuation. 2. Patients and methods The four patients included in this study had chronic sci- atica or femoral neuralgia. Details are provided on findings from the physical examination, lumbar spine CT, elec- tromyogram (one patient), and laboratory tests (Lyme serol- ogy, western blot, PCR [1,2] and HLA type) in these patients. Serological tests for Lyme disease were positive in the blood and cerebrospinal fluid (CSF) in all four patients. We did not obtain direct proof that B. burgdorferi was present because PCR testing for the bacterial DNA was done in only two patients and could not be interpreted, due to presence of an inhibitor in one patient and to a technical problem in the other. 3. Case-reports 3.1. Case 1 This 63-year-old man with an unremarkable medical his- tory was admitted for low back pain and femoral neuralgia on the left side that had started 4 months earlier and failed to respond to medical therapy. He had moderately severe spinal symptoms, L4 neuralgia on the left made worse by coughing, blunting of the left knee reflex, and a positive contralateral straight leg-raising test. No severe motor or sensory loss was found. CT of the lumbar spine showed herniation of the L3–L4 disk on the left and of the L5–S1 disk on the midline. * Corresponding author. Service de médecine Physique et Réadaptation, Hôpitaux Universitaires de Strasbourg, Avenue Molière, 67098 Strasbourg cedex, France. E-mail address: arnaud.dupeyron@chru-strasbourg.fr (A. Dupeyron). Joint Bone Spine 71 (2004) 433–437 www.elsevier.com/locate/bonsoi © 2003 Elsevier SAS. All rights reserved. doi:10.1016/j.jbspin.2003.09.002