Factors predicting failure of conservative treatment in lumbar-disc herniation.
ABSTRACT To explore factors predicting failure of conservative treatment in lumbar-disc herniation.
Sciatica due to lumbar-disc herniation is a common complaint of spine patients. Even though the natural course is favorable, surgery is necessary in at least 10% of cases. Current trends show surgery to be more cost-effective than prolonged conservative care. However; there is limited information about the usefulness of clinical and radiographic parameters to classify patients who are likely to fail conservative treatment.
Medical records of patients diagnosed with lumbar-disc herniation between January 1, 2007 and December 31, 2009 were studied. The records of patients in conservative and surgery groups were compared, for clinical features, MRI results and treatment modalities.
Fifty cases (discectomy) and 50 controls (successful conservative treatment) were enrolled. Demographic data, presenting symptoms and physical examination did not differ apart from duration of symptoms. Logistic regression analysis did not find a significant association between percentage of canal compromised after controlling for disc-fragment size, duration of symptoms and types of disc herniation. However disc fragment size was strongly associated with surgical outcome (OR = 2.6). Duration of symptoms (OR = 1.2) and sequestered type of lesion (OR = 12.3) were associated with surgery in this model. The use of physiotherapy and epidural steroid injections was lower but the failure rate was higher.
Long-duration, sequestered herniation and large fragment are predictive of failure in the conservative treatment of lumbar-disc herniation.
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ABSTRACT: In the present study, the influence of cytokines on 1-year recovery in lumbar radicular pain was examined. In total, 110 patients with symptomatic lumbar disc herniation were followed for 1 year. Uni- and multivariate linear regression was used to assess the influence of interleukin (IL)-6, IL-8, disc degeneration and endplate changes (Modic changes) on the changes in the Oswestry Disability Index (ODI change; primary outcome) and visual analogue scale (VAS) for low back pain (LBP) and leg pain (secondary outcomes). Less favourable ODI outcome correlated with higher serum IL-6 levels (B = -3.41, 95% CI -5.52 to -1.30, p = 0.002), non-surgical treatment (B = -7.03, 95% CI 1.21 to 12.84, p = 0.018), higher baseline back pain intensity (B = -2.28, 95% CI -3.21 to -1.35, p < 0.001) and low educational level (B = -5.57, 95% CI 0.66 to 10.47, p = 0.027). High VAS for LBP and leg pain at 1 year was associated with high levels of serum IL-6, higher back pain intensity and longer duration of lumbar radicular pain at baseline. High serum IL-6 levels, but not disc degeneration or Modic changes, were associated with less favourable recovery in patients with lumbar radicular pain. Intense initial back pain, non-surgical treatment, lower educational level and longer duration of radicular pain before treatment also correlated with a slower recovery the first year after disc herniation.European journal of pain (London, England) 11/2014; 18(10). DOI:10.1002/j.1532-2149.2014.502.x · 3.37 Impact Factor
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ABSTRACT: Herniation of nucleus pulposus leading to leg pain is the commonest indication for lumbar spine surgery. However, there is no consensus when to stop conservative treatment and when to consider for surgery. A systematic review of literature was done to find a consensus on the issue of when should surgery be performed for herniation of nucleus pulposus in lumbar spine was conducted. Electronic database searches of Medline, Embase and Pubmed Central were performed to find articles relating to optimum time to operate in patients with herniation of nucleus pulposus in lumbar spine, published between January 1975 and 10 December 2012. The studies were independently screened by two reviewers. Disagreements between reviewers were settled at a consensus meeting. A scoring system based on research design, number of patients at final followup, percentage of patients at final followup, duration of followup, journal impact factor and annual citation index was devised to give weightage to Categorize (A, B or C) each of the articles. Twenty one studies fulfilled the criteria. Six studies were of retrospective design, 13 studies were of Prospective design and two studies were randomized controlled trials. The studies were categorized as: Two articles in category A (highest level of evidence), 12 articles in category B (moderate level of evidence) while seven articles in Category C (poor level of evidence). Category A studies conclude that duration of sciatica prior to surgery made no difference to the outcome of surgery in patients with herniation of nucleus pulposus in the lumbar spine. Ten out of 12 studies in Category B revealed that longer duration of sciatica before surgery leads to poor results while 2 studies conclude that duration of sciatica makes no difference to outcome. In category C, five studies conclude that longer duration of sciatica before surgery leads to poor outcome while two studies find no difference in outcome with regards to duration of sciatica. A qualitative and quantitative analysis was performed which favoured the consensus that longer duration of sciatica leads to poorer outcome. A systematic and critical review of literature revealed that long duration of preoperative leg pain lead to poor outcome for herniation of nucleus pulposus. Only a broad time frame (2-12 months) could be derived from the review of literature due to lack of high quality studies and variable and contrasting results of the existing studies. While surgery performed within six months was most commonly found to lead to good outcome of surgery, further studies are needed to prove this more conclusively. At this stage it is felt that time alone should not be the basis of recommending surgery and multiple other variables should be considered in a shared decision making process between the surgeon and the patient.Indian Journal of Orthopaedics 01/2014; 48(2):127-135. DOI:10.4103/0019-5413.128740 · 0.62 Impact Factor
Conference Paper: Diagnosis parameters used in treatment prediction of the lumbar spine[Show abstract] [Hide abstract]
ABSTRACT: The paper proposes to define three parameters that can be associated with lumbar spine diagnosis. These parameters will further be used in a prediction software that aims to establish a treatment indication in the early stages of the medical exploration. These parameters quantifies very different conditions of the patient: pain - a very subjective parameter; the calories consumed in one day - measurable value; biomechanical parameters like range of motion in lumbar spine and postural angle - measurable parameter. These parameters have to be interconnected and therefore recordings before and after surgery and treatment have to be made. The interconnection of those represents a challenging task that requires a large patient's database from which the statistics can be computed. Another cornerstone in interconnection is the lake of biomechanical statistics on the lumbar spine pathologies.Applied Computational Intelligence and Informatics (SACI), 2013 IEEE 8th International Symposium on; 01/2013