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Sciatica from disk herniation: Medical treatment or surgery?
Abstract
Disk-related sciatica is a common disorder that resolves without surgery in 95% of patients within 1 to 12months. Several treatment strategies designed to hasten recovery, enable a return to previous social and occupational activities, and prevent chronicization have been evaluated. Available efficacy data support the use of analgesics, nonsteroidal anti-inflammatory drugs, and epidural steroid injections, which probably relieve the pain and improve the quality of life without radically changing the midterm outcome. After a specialized evaluation of physical, psychological, social, and occupational factors, surgery may be offered to patients with persistent nerve root pain (as opposed to low back pain). The complication rate ranges from 1% to 3%. Surgery is clearly effective, shortening the time to recovery by about 50% compared to nonsurgical treatment. Whether one specific surgical procedure is better than others remains unclear. Methodological weaknesses of studies evaluating the efficacy of percutaneous methods preclude definitive conclusions. Bed rest, systemic glucocorticoid therapy, spinal manipulation, bracing, spinal traction, and physical therapy have no proven effects on the outcome of sciatica.
... However, complete bed rest results in muscle deconditioning, and certain activities can exacerbate LBP [75]. There is no evidence to support the use of rigid braces in LBP [76]. ...
... Although, NSAIDs are thought to be effective in acute and chronic LBP, their effectiveness in sciatica remains unproven [77]. Analgesics have been shown to reduce the rate of surgery and improve quality of life [76]. Opioids are considered for patients with intractable pain [5,72]. ...
... The role of antidepressant drugs in chronic low back pain remains unclear and is not strongly supported by the literature [76]. Although, anti-depressants have no effect on radicular pain, they may help alleviate LBP [5]. ...
Acute low back pain (LBP) with associated sciatica is a common problem leading patients to see a physician. It is usually a benign and self-limited disorder. Radicular pain in the distribution of the sciatic nerve, resulting from herniation of one or more lumbar intervertebral discs, is a common and painful event. The lifetime incidence of this situation is expected to be between 13% and 40%. Compression of a lumbar nerve root by a herniated intervertebral disc is a common cause of sciatica. Non-discogenic causes of sciatica include benign and malignant tumors, infections including epidural abscess and discitis, vascular compression, bony compression due to spinal stenosis, epidural adhesions, Piriformis syndrome, or compression by gynecological structures (i.e. uterine fibroid, pelvic endometriosis).The evidence suggests that a multifactorial interaction of inflammatory, immunological, and pressure-related processes may play a role in the pathophysiology of sciatica neuralgia. Sciatica is a clinical diagnosis. The history and physical examination can frequently reveal the etiology..Imaging studies including MRI or CT myelograms may help with the diagnosis and in selecting specific treatment plans. Several conservative and surgical therapeutic options are available for management of discogenic sciatica. Physical therapy, activity modification, nonsteroidal anti-inflammatory drugs and analgesics are the most commonly prescribed treatment. While commonly used, physical therapy, epidural steroid injections, systemic glucocorticoid therapy, trigger point injectionsspinal manipulation, bracing, and traction have little support in the literature. Different types of electro-acupuncture stimulation have had mixed results in sciatica patients. Further clinical trials are necessary to confirm their efficacy. Chemonucleolysis is the last step of conservative management in patients without extruded disk material. Allergic reactions are a possible severe complication and plans should be in place to deal with any reaction that might occur. There is limited scientific data supporting this treatment. This procedure does not affect the outcome of the later surgery if necessary. Surgical discectomy may be considered for selected patients with sciatica due to lumbar disc herniations that fail to resolve with the conservative management or in patients with severe paralysis or a cauda equina syndrome. To prevent complications, an appropriate pre-operative work up including neuroimaging is necessary, especially when there is a lack of correlation between the history, physical examination, or radiologic examination. Surgery has been shown to be highly effective, shortening the time to recovery by about 50% compared to nonsurgical treatment. Whether one specific surgical procedure is better than others remains uncertain. Methodological limitations of studies evaluating the efficacy of percutaneous methods prevent ultimate conclusions. Post-operative complications occur in 1% to 3% of cases. If patients were appropriately selected, failures happen in less than 10% of cases, which are primarily due to recurrent disc herniation or fibrosis. After pain is controlled, a multidisciplinary approach including physical, psychological, socioeconomic, and self-management techniques is recommended.
... The economic burden of low back pain is large and growing (Olafsson et al., 2017). Most patients recover without surgery; 80 per cent of patients recover within 8 weeks and 95 per cent recover within one year (Legrand et al., 2007). When patients consult a physician for low back pain, conservative treatment (e.g. ...
... Surgery is considered if a degenerative spine disorder, such as disc herniation or spinal stenosis, is diagnosed and confirmed by radiological methods. Approximately 85 percent of surgically treated patients are fully recovered (Legrand et al., 2007) but it can be difficult to distinguish which patients in the end will benefit from surgery. Recommendations and clinical guidelines within elective spine surgery vary (Foster et al., 2018). ...
... Most people with lumbar disc herniation (LDH) improve with nonsurgical treatment [2]. However, the Danish national clinical guidelines for nonsurgical treatment of recent onset lumbar nerve root compression recommend surgical evaluation if patients have ongoing severe pain and disability after 12 weeks of conservative care [3]. ...
... To support SDM in clinical settings the Centre has developed a generic PtDA, in Danish called BESLUTNINGSH-JAELPER™ in English a "Decision Helper" [22], according to the IPDAS criteria [23][24][25] and in collaboration with designers from Design School Kolding, Denmark. The BESLUTNINGSHJAELPER™ is a folder containing looseleaf cards, called option cards (Fig. 2)".The PtDA consists of five sections, as described by Olling et al. [22]: [1] the health care provider presents the PtDA and outlines the decision to be made [2]; the options are presented and the patient's preference for level of information is assessed [3]; the patient's preferences, fears and expectations are clarified and discussed [4]; different cards where information about advantages and disadvantages of the individual options, statistics, timelines and patient stories can be presented; and [5] assessment of readiness to make a decision, including the possibility of deferring the decision. In this current project the template was adapted to treatment choices for LDH and populated with specific content concerning LDH, the actual decision, advantages and disadvantages of each treatment, patient narratives etc. ...
Background:
Shared decision making (SDM) is a systematic approach aimed at improving patient involvement in preference-sensitive health care decisions. Choosing between surgical or non-surgical treatment for lumbar disc herniation, can be difficult as the evidence of a superior treatment is unclear, which makes it a preference-sensitive decision. The objectives of this study was therefore to assess the degree of SDM and afterwards to develop and test a patient decision aid (PtDA) to support SDM during the clinical encounter between surgeon and patient, when patients choose between surgical and non-surgical treatment for Lumbar disc herniation (LDH).
Methods:
The study was conducted in four steps. 1) Assessment of the extent to which SDM was practiced in the spine clinic. 2) Development of a PtDA to support SDM. 3) Testing its usability and acceptability amongst potential users (patients). 4) Pilot-test of its usability in the clinical setting.
Results:
Results from our small baseline study (n = 40) showed that between a third and two-thirds of the patients reported not being fully engaged in a shared decision. A pre-designed template (BESLUTNINGSHJÆLPER™) was adapted to support the decision about whether or not to have surgery for LDH. Testing the prototype with patients led to minor refinements. A subsequent pilot test of its usability in a clinical setting achieved positive responses from both patients and clinicians.
Conclusion:
Our baseline study demonstrated that SDM was not universally practiced in the clinic. The PtDA we have developed was rated as acceptable and usable by both patients and clinicians for helping those with LDH choose between surgical or non- surgical treatment. This tool now requires further testing to assess its effectiveness.
... The current gold standard for the treatment of this condition is surgery [13]. A successful surgical procedure brings about fast and effective pain management and fast recovery and return to a normal independent life [13,14]. Moreover, it dramatically reduces the need for anti-inflammatory drugs, thus minimizing the serious side effects of NSAIDs and opioids [14]. ...
... A successful surgical procedure brings about fast and effective pain management and fast recovery and return to a normal independent life [13,14]. Moreover, it dramatically reduces the need for anti-inflammatory drugs, thus minimizing the serious side effects of NSAIDs and opioids [14]. ...
Extrusion of disc material within the spinal canal complicates up to 28.6% of lumbar disc herniations. Due to the anatomical “corridors” created by the anterior midline septum and lateral membranes, relocation occurs with an anterior and anterolateral axial topography. Posterior migration is an extremely rare condition and anterior-to-posterior circumferential migration is an even rarer condition. Its radiological feature can be enigmatic and since, in more than 50% of cases, clinical onset is a hyperacute cauda equina syndrome, it may imply a difficult surgical decision in emergency settings. Surgery is the gold standard but when dealing with such huge sequestrations, standard microdiscectomy must be properly modified in order to minimize the risk of surgical trauma or traction on the nerve roots.
... Medical treatment is the first step in therapy for lumbar disc herniation (LDH), except for patients who require immediate surgical decompression. Drugs that are utilized in treatment of LDH pain and sensory deficits include muscle relaxants [1][2][3], analgesics [1,2,[4][5][6][7][8][9], corticosteroids [1,2,10], antidepressants [4,8,11,12] and antiepileptics [4,8,[11][12][13][14][15][16][17]. ...
... 1. Effect of vitamin D 3 on discogenic pain 2. Effect of vitamin D 3 on discogenic sensory deficits 3. Effect of posttreatment 25-hydroxy vitamin D 3 level on pain and sensory deficit severity 4. Determining a cut-off level of 25-hydroxy vitamin D 3 that is efficient in improving pain and sensory deficits ...
Background
Vitamin D receptors have been identified in the spinal cord, nerve roots, dorsal root ganglia and glial cells, and its genetic polymorphism association with the development of lumbar disc degeneration and herniation has been documented. Metabolic effects of active vitamin D metabolites in the nucleus pulposus and annulus fibrosus cells have been studied. Lumbar disc herniation is a process that involves immune and inflammatory cells and processes that are targets for immune regulatory actions of vitamin D as a neurosteroid hormone. In addition to vitamin D’s immune modulatory properties, its receptors have been identified in skeletal muscles. It also affects sensory neurons to modulate pain. In this study, we aim to study the role of vitamin D3 in discogenic pain and related sensory deficits. Additionally, we will address how post-treatment 25-hydroxy vitamin D3 level influences pain and sensory deficits severity. The cut-off value for serum 25-hydroxy vitamin D3 that would be efficacious in improving pain and sensory deficits in lumbar disc herniation will also be studied.
Methods/Design
We will conduct a randomized, placebo-controlled, double-blind clinical trial. Our study population will include 380 cases with one-level and unilateral lumbar disc herniation with duration of discogenic pain less than 8 weeks. Individuals who do not have any contraindications, will be divided into three groups based on serum 25-hydroxy vitamin D3 level, and each group will be randomized to receive either a single-dose 300,000-IU intramuscular injection of vitamin D3 or placebo. All patients will be under conservative treatment. Pre-treatment and post-treatment assessments will be performed with the McGill Pain Questionnaire and a visual analogue scale. For the 15-day duration of this study, questionnaires will be filled out during telephone interviews every 3 days (a total of five times). The initial and final interviews will be scheduled at our clinic. After 15 days, serum 25-hydroxy vitamin D3 levels will be measured for those who have received vitamin D3 (190 individuals).
Trial registration
Iranian Registry for Clinical Trials ID: IRCT2014050317534N1 (trial registration: 5 June 2014)
... Since sciatica causes loss of work force as well as lowering the living standards, it is very important to be treated effectively. Today, the treatment goal of sciatica is; It is the alleviation of all symptoms in the short-medium periods and the reduction of functional disability in the long term (1,2). ...
Introduction: Lumbar disc herniation (LDH); It is an important disease that is common in society and can cause socioeconomic problems. There are many treatment algorithms for LDH, including medical and surgical. Our aim in this study; To evaluate the clinical results of patients with LDH who did not benefit from conservative treatment after percutaneous intradiscal radiopaque gel ethanol (RGE) procedure in the light of the literature. Methods: A total of 44 levels of percutaneous intradiscal RGE were applied to 41 patients, 14 men and 27 women, hospitalized with the diagnosis of LDH. patients; Demographic characteristics, treatments they received, lumbar magnetic resonance imaging (MRI) taken 6 months later, visual analog scores (VAS) before and 6 months after percutaneous intradiscal RGE procedure, complications, side effects and patient satisfaction after the procedure were evaluated. Results: The VAS values of the patients were 8 before the procedure and 4.2 6 months after the procedure. A 47.5% reduction in pain was observed and these data were evaluated as statistically significant. When patients were asked about their satisfaction with the procedure after the percutaneous RGE procedure; 4 patients answered "poor", 13 patients "moderate", 13 patients "good" and 11 patients "excellent". The rate of those who were satisfied with the procedure was 90.2%, and these data were not considered statistically significant. Conclusion: As a result; Percutaneous intradiscal RGE procedure, in patients with a diagnosis of LDH and who did not benefit from conservative treatment; It can be a minimally invasive technique that reduces pain.
... [4,5,6] Although the prognosis is good in most patients, a substantial proportion continues to have pain for 1 year or longer. [7,8] Physiotherapy treatment of acute sciatica includes cold therapy, rest, manual therapy (spinal manipulation and soft tissue mobilization) and electrotherapy, [9] core muscle strengthening, stretching of tight structures, mechanical traction. [10] However, there are still contentions on the Physiotherapy treatment protocols which produce a rapid improvement in patients with sciatica [9,11] though a systematic review [12] reported that exercises seemed not to produce therapeutic benefits. ...
Abstract
Introduction: Sciatica is one of the most common
painful and disabling conditions accounting for
about 40% of low back pain cases hence the need
for effective means to alleviate symptoms. Nerve
Flossing Technique has been successfully used to
manage neuropathic pain like carpal tunnel
syndrome.
Aim: This study investigated the efficacy of nerve
flossing technique (NFT) in the relief of symptoms
of acute sciatica and the attendant functional
disabilities.
Method: In this randomized control trial, 32
participants between the ages of 18 – 64 years with
acute sciatica were randomly assigned into two
groups; Group A (Study Group) received Nerve
Flossing Technique (NFT) in addition to
Conventional Physiotherapy and group B (Control
Group) received only Conventional Physiotherapy.
The outcome was assessed in terms of Numeric Pain
Rating Scale (NPRS), Passive Straight Leg Raise
(PSLR) and Sciatica Bothersomeness Index (SBI).
Result: Both groups had significant improvement
in NPRS score (p<0.01), PSLR value (p<0.01) and
SBI score (p<0.01). However, comparing the mean
changes in the outcome measures between the two
groups showed that the study group had significant
(p<0.01) changes in all outcome measures when
compared to the control group.
Conclusion: NFT combined with conventional
physiotherapy has a better effect on the
management of acute sciatica and should be an
integral component of physiotherapy management.
... Intervertebral disk degeneration is a common reason for LBP, which is one of the leading causes of chronic disability. To date, conventional treatments including physical therapy, anti-inflammatory medications, and surgeries remain unsatisfactory (Legrand et al., 2007). Therefore, development of biological therapies to prevent IDD is an issue that needs to be solved urgently. ...
Objective
The aim of this study is to explore the role of Parkin in intervertebral disk degeneration (IDD) and its mitophagy regulation mechanism.
Study design and methods
Rat nucleus pulposus (NP) cells were stimulated with hydrogen peroxide (H 2 O 2 ) to a mimic pathological condition. Apoptosis and mitophagy were assessed by Western blot, terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay, and immunofluorescence staining. The CRISPR–dCas9–KRAB system was used to silence the expression of Parkin.
Result
In this study, we found that Parkin was downregulated in rat NP cells under oxidative stress. In addition, treatment with H 2 O 2 resulted in mitochondrial dysfunction, autophagy inhibition, and a significant increase in the rate of apoptosis of NP cells. Meanwhile, mitophagy inhibition enhanced H 2 O 2 -induced apoptosis. Furthermore, repression of Parkin significantly attenuated mitophagy and exacerbated apoptosis.
Conclusion
These results suggested that Parkin may play a protective role in alleviating the apoptosis of NP cells via mitophagy, and that targeting Parkin may provide a promising therapeutic strategy for the prevention of IDD.
... 5 Despite the severity of symptoms, most patients with lumbar radiculopathy spontaneously recover within 1 year. 6,7 Therefore, patients are initially treated conservatively for several weeks before consultation with a neurologist and extensive radiologic imaging, 8 considering the absence of warning signs that require immediate attention. After referral, surgical options can be discussed with the neurosurgeon, but generally, patients are encouraged to prolong conservative therapy up to 16 weeks. ...
Objective
Lumbar radiculopathy is a condition with major physical, social and economic consequences. Despite its favourable prognosis the burden can be significant. In this study, we aimed to determine the value of MRI and the efficacy of transforaminal epidural injections (TEI) in patients with lumbar radiculopathy secondary to lumbar disc herniation (LDH) and other causes (non-LDH).
Methods
Patients with lumbar radiculopathy were reviewed for radiological diagnosis based on MRI. For patients receiving TEI therapy, response after 6-8 weeks (short term) and 16 weeks (long term), number of injections, subsequent surgery and eventual patient outcome were evaluated. Treatment response was assessed by patient-reported symptom relief and NRS pain scores.
Results
Overall, 66% of MRI examinations demonstrated a clinically relevant LDH. 486 out of 1824 patients received TEI of which one-third did not demonstrate LDH. 70% of patients reported a short-term effect with significant pain reduction and 44% reported a long-term effect. No significant differences were observed between the LDH and non-LDH groups. 59% of patients required multiple injections, and eventually reported similar efficacy compared to patients treated with a single injection.
Conclusions
A considerable part of MRI examinations in patients with lumbar radiculopathy does not demonstrate a clinically relevant LDH. Regardless of the radiological diagnosis the majority of patients treated with TEI benefits on both short and long term after a single or multiple injections regime. Subsequent injections are advisable if the effect from the first injection is unsatisfactory or wears off. MRI examination before TEI therapy may be redundant which allows for expedition of this treatment.
... [2,3] The prevalence of sciatic symptoms reported in the literature varies considerably ranging from 1.6% in the general population to 43% in a selected working population. [4] Although the prognosis is good in most patients, [5] a substantial proportion (up to 30%) continues to have pain for 1 year or longer. [6,7] In approximately 90% of the cases, sciatica is caused by a herniated disc involving nerve root compression. ...
... [2,3] The prevalence of sciatic symptoms reported in the literature varies considerably ranging from 1.6% in the general population to 43% in a selected working population. [4] Although the prognosis is good in most patients, [5] a substantial proportion (up to 30%) continues to have pain for 1 year or longer. [6,7] In approximately 90% of the cases, sciatica is caused by a herniated disc involving nerve root compression. ...
Introduction: Gridhrasi (Sciatica) is the degenerative changes affecting lumbar region. The management of Sciatica in conventional medicine is temporary and many cases require surgical treatment. The Non-Steroidal Anti-Inflammatory Drugs (NSAID's) and analgesics are the main drug; however they have serious adverse effects and have limitations for a long term use. Objectives: The study was designed to evaluate the relative efficacy of Karma Basti in two formats in the management of Gridhrasi (sciatica). Material and Methods: This was a simple-randomized, comparative clinical study conducted in two groups of 60 clinically diagnosed registered patients of Gridhrasi from the OPD and IPD. In 1 st group i.e. A, Karma Basti was planned in 30 patients with Vrishadi-Niruha Basti and Vajigandhadi Anuvasana Basti for 30 days and in 2 nd group i.e. B, Karma Basti was planned in 30 patients with Vrishadi-Niruha Basti and Vajigandhadi Anuvasana Basti for 18 days. Observations and Results: Symptomatically and statistically significant (p<0.001)improvement was observed in all clinical parameters in majority of the cases. Overall effects of therapy on the basis of subjective criteria's Group A shows 71.71% improvement and Group B shows 79.86% improvement. Overall effects of therapy on the basis of Objective criteria's Group A shows 65.66% improvement and Group B shows 70.73% improvement. Conclusion: On comparing the overall effect of the therapy, Group B was more effective than Group A.
... 5 Despite the severity of symptoms, most patients with lumbar radiculopathy spontaneously recover within 1 year. 6,7 Therefore, patients are initially treated conservatively for several weeks before consultation with a neurologist and extensive radiologic Key words -Epidural steroid injection -Lumbar disc herniation -Lumbar radiculopathy -Magnetic resonance imaging -Transforaminal epidural injection Abbreviations and Acronyms LDH: Lumbar disc herniation MRI: Magnetic resonance imaging NRS: Numeric rating scale TEI: Transforaminal epidural injection imaging, 8 considering the absence of warning signs that require immediate attention. After referral, surgical options can be discussed with the neurosurgeon, but generally, patients are encouraged to prolong conservative therapy up to 16 weeks. ...
Objective: To develop and validate an outcome scale for the cervical radicular syndrome and to build a mapping, predicting EQ-5D utility from the new scale.
Study design and setting: An item pool was developed based on literature and patient and clinician interviews. Item selection was based on symptomatology, factor analysis, and internal consistency. We assessed: (a) test–retest reliability by standard error of measurement and intraclass correlation coefficients; (b) construct validity by testing 22 hypotheses on relationships with existing measures and known-group differences. For the mapping, performance was assessed by mean absolute error and root mean squared error.
Results: A total of 254 patients with cervical radicular syndrome completed the first questionnaire, 61 stable patients a retest. Item selection led to a 21-item questionnaire consisting of three subscales: Symptoms, Energy and postures, and Actions and activities. Standard error of measurement values ranged from 6.7 to 11.2 on a 0 to 100 scale. All subscales showed good reliability (intraclass correlation coefficients: 0.84, 0.87, and 0.94). All hypotheses for construct validity were confirmed. A linear utility mapping was preferred, with reasonable statistical performance.
Conclusion: We developed a reliable and valid cervical radicular syndrome specific outcome scale, called the Cervical Radiculopathy Impact Scale (CRIS). This new questionnaire may facilitate (cost-)effectiveness studies in this field.
• Implications for Rehabilitation
• The cervical radicular syndrome is a frequently occurring and invalidating health problem, which causes severe radiating pain in the arm and/or hand, which can be accompanied by motor and/or sensory deficits.
• The Cervical Radiculopathy Impact Scale (CRIS) is a newly developed self-report questionnaire which covers measurement of symptoms and limitations in patients with cervical radiculopathy due to irradiating pain, tingling sensations and sensory loss in the arm in combination with neck disability.
• The CRIS consists of 21 items divided over three subscales: (i) symptoms, (ii) energy and postures, and (iii) actions and activities.
• The CRIS shows good content validity, test-retest reliability, construct validity and is able to discriminate between groups.
• The CRIS predicts EQ-5D utility and is therefore useful for (cost)effectiveness studies in this field.
... Дискогенная радикулопатия встречается в клинической практике значительно реже (менее 5%) [3], однако пациенты с корешковым синдромом имеют более интенсивную боль, выраженное нарушение трудоспособности и снижение качества жизни. В связи с этим возрастает объем лечебных и диагностических мероприятий, увеличиваются прямые и косвенные затраты [4][5][6]. При дискогенной радикулопатии применяются как хирургический, так и консервативные методы лечения, при этом большинство пациентов имеют положительный эффект от консервативной терапии [2,7]. Хирургическое лечение позволяет быстрее снять боль и связанную с ней временную инвалидность, однако состояние пациентов постепенно улучшается и при консервативном ведении, и через год наблюдения © Коллектив авторов, 2018 *Регресс грыжи диска как естественное течение дискогенной пояснично-крестцовой радикулопатии М.А. ...
Disc herniation with radiculopathy is a common cause of severe back pain leading to significant disability and a decrease in patients’ quality of life. The authors report a case of 38-year-old female patient with radiculopathy of the first sacral root due to a large (11 mm) sequestered disc herniation between the fifth lumbar and the first sacral vertebrae. Conservative treatment with flu-oroscopically-guided epidural steroid injection provided a significant clinical improvement, the patient was able to return to normal daily and professional activity in a short time. MRI in 9 months showed the regression of disc herniation. Possible predictors and timing of disc herniation regression are discussed, as well as the proposed mechanisms, the main one of which is considered to be immune-mediated lysis.
... 18,20,36 Referral to a spinal surgeon should be reserved for patients for whom conservative care has proven insufficient and who have disabling symptoms that have persisted for longer than 6 weeks, 37,38 for patients who have severe or progressive neurological deficit, and for patients with cauda equina syndrome. 39 A recent trial showing similar outcomes for decompression surgery and conservative managementphysiotherapist-delivered education combined with flexion-bias and conditioning exercisesprovides support for conservative management of spinal stenosis. 36 Another study found no clinically important improvement in symptoms and function after surgery in 57% of patients. ...
Diagnostic triage is an essential guideline recommendation for low back pain (LBP), which is the most frequent musculoskeletal condition that general practitioners encounter in Australia. Clinical diagnosis of LBP — informed by a focused history and clinical examination — is the key initial step for GPs, and determines subsequent diagnostic workup and allied health and medical specialist referral. The goal of diagnostic triage of LBP is to exclude non-spinal causes and to allocate patients to one of three broad categories: specific spinal pathology (< 1% of cases), radicular syndrome (~5-10% of cases) or non-specific LBP (NSLBP), which represents 90-95% of cases and is diagnosed by exclusion of the first two categories. For specific spinal pathologies (eg, vertebral fracture, malignancy, infection, axial spondyloarthritis or cauda equina syndrome), a clinical assessment may reveal the key alerting features. For radicular syndrome, clinical features distinguish three subsets of nerve root involvement: radicular pain, radiculopathy and spinal stenosis. Differential diagnosis of back-related leg pain is complex and clinical manifestations are highly variable. However, distinctive clusters of characteristic history cues and positive clinical examination signs, particularly from neurological examination, guide differential diagnosis within this triage category. A diagnosis of NSLBP presumes exclusion of specific pathologies and nerve root involvement. A biopsychosocial model of care underpins NSLBP; this includes managing pain intensity and considering risk for disability, which directs matched pathways of care. Back pain is a symptom and not a diagnosis. Careful diagnostic differentiation is required and, in primary care, diagnostic triage of LBP is the anchor for a diagnosis. © 2017 AMPCo Pty Ltd. Produced with Elsevier B.V. All rights reserved.
... However, most patients present with a less clear clinical picture. 5 These presentations were, also, common in ancient era and Ayurveda named it as ...
... [4,5] Available efficacy data supported that the use of analgesics, nonsteroidal anti-inflammatory drugs and epidural steroid injections probably could relieve the associated pain and improve the quality of life without radically changing the midterm outcome. [6] In our study, based on researches of mechanisms of LDH and injection therapy, we speculate that local irrigation of herniated lumber disc area may have a positive effect. To verify this, this study systematically evaluates the effect of local lavage during microdiscectomy by assessing some outcomes of indexes of 410 patients, and tries to find that whether the local intervertebral irrigation is an efficient way in reducing postoperative low back and leg radicular pain. ...
Lumbar disc herniation (LDH) is a common disease and lumbar discectomy is the most common surgical procedure carried out for patients with low back pain and leg symptoms. Although most researchers are focusing on the surgical techniques during operation, the aim of this study is to evaluate the effect of local intervertebral lavage during microdiscectomy.
In this retrospective study, 410 patients were operated on by microdiscectomy for LDH during 2011 to 2014. Retrospectively, 213 of them (group A) accepted local intervertebral irrigation with saline water before wound closure and 197 patients (group B) only had their operative field irrigated with saline water. Systematic records of visual analog scores (VAS), Oswestry disability Index (ODI) questionnaire scale scores, use of analgesia, and hospital length of stay were done after hospitalization.
The majority (80.49%) of the cases were diagnosed with lumber herniation at the levels of L4/5 and L5/S1. Fifty-one patients had herniations at 2 levels. There were significant decreases of VAS scores and ODI in both groups between preoperation and postoperation of different time points. VAS scores decreased more in group A than group B at early stage of postoperation follow-up. However, there were no statistically significant differences between 2 groups in using analgesia, VAS and ODI up to 1 month of follow-up.
Microdiscectomy for LDH offers a marked improvement in back and radicular pain. Local irrigation of herniated lumber disc area could relief dick herniation-derived low back pain and leg radicular pain at early stage of post-operation. However, the pain relief of this intervention was not noticeable for a long period.
... 18,20,36 Referral to a spinal surgeon should be reserved for patients for whom conservative care has proven insufficient and who have disabling symptoms that have persisted for longer than 6 weeks, 37,38 for patients who have severe or progressive neuro- logical deficit, and for patients with cauda equina syndrome. 39 A recent trial showing similar outcomes for decompression surgery and conservative management -physiotherapist-delivered ed- ucation combined with flexion-bias and conditioning exercises - provides support for conservative management of spinal steno- sis. 36 Another study found no clinically important improvement in symptoms and function after surgery in 57% of patients. ...
A comprehensive understanding of low back pain (LBP)
has evolved that necessitates the use of a biopsychosocial model, focusing on illness rather than disease and incorporating the biological, psychological and social aspects that are important to understand and to study LBP in its chronic form. Traditional outcome measures that measure elements within the biological component are limited to assess the spectrum of impacts caused by chronic low back pain (CLBP) and the validity, reliability and sensitivity of some of these measures has been questioned.Few physiologic tests of spine function are clinically meaningful to patients, objective physical findings can be absent, and in CLBP disability and activity intolerance are often disproportional to the original injury. Biological outcomes should be complemented by outcomes of the psychosocial aspects of back pain that measure the considerable functional and emotional impact on the quality of life of patients experiencing low back dysfunction. Outcomes research is an analysis of clinical practice as it actually occurs and can make a valuable contribution to understanding the multidimensional impact of LBP. Psychosocial aspects of the biopsychosocial model for outcomes research are discussed in part III: functional status/disability, psychological impairment, patient satisfaction, health related quality of life
... Moreover, reoperations lead to physical and psychological suffering for patients and substantial costs for society. 9,10 Risk factors for rLDH are increasingly being investigated. [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] Many estimated risk factors have been reported in previous studies, such as age, gender, body mass index (BMI), smoking, herniation type, diabetes, and herniation level. ...
Recurrent lumbar disc herniation (rLDH) is a common complication following primary discectomy. This systematic review aimed to investigate the current evidence on risk factors for rLDH.
Cohort or case-control studies addressing risk factors for rLDH were identified by search in Pubmed (Medline), Embase, Web of Science, and Cochrane library from inception to June 2015. Relevant results were pooled to give overall estimates if possible. Heterogeneity among studies was examined and publication bias was also assessed.
A total of 17 studies were included in this systematic review. Risk factors that had significant relation with rLDH were smoking (OR 1.99, 95% CI 1.53–2.58), disc protrusion (OR 1.79, 95% CI 1.15–2.79), and diabetes (OR 1.19, 95% CI 1.06–1.32). Gender, BMI, occupational work, level, and side of herniation did not correlate with rLDH significantly.
Based on current evidence, smoking, disc protrusion, and diabetes were predictors for rLDH. Patients with these risk factors should be paid more attention for prevention of recurrence after primary surgery. More evidence provided by high-quality observational studies is still needed to further investigate risk factors for rLDH.
... Therefore, while treating patients with sciatica caused by LDH, the objective is to relieve their pain and improve their quality of life(QOL) as soon as possible by conservative treatment. As a part of this treatment, patients are initially treated with medications and physical therapies；however, if pain continues to compromise their QOL even after 2 weeks of nonsteroidal anti-inflammatory drugs(NSAIDs), epidural injections are recommended 5) . The epidural injections deliver steroids with strong anti-inflammatory activity as well as topical anesthetics directly to the inflamed nerve roots to suppress pain and inflammation 6) 7) . ...
Purpose: Identifying prospective predictors of a poor treatment outcome in acute to subacute sciatica would be of great importance for clinical practice. This study aimed to determine what baseline factors are associated with short- to medium-term outcomes on acute to subacute sciatica caused by lumbar disk herniation (LDH) after epidural injections.
Methods: Variables including demographic data, neurological and radiological examination, the visual analog scale (VAS), the Roland-Morris Disability Questionnaire (RMDQ), and the Spielberger State-Trait Anxiety Inventory from 48 LDH patients (25 males and 23 females between 20 and 60 years old) with acute to subacute sciatica before and 1, 3, and 6 months following epidural injections were measured. A poor outcome was defined as a VAS reduction of less than 50% or a RMDQ reduction of less than an important change.
Results: In multiple logistic regression analysis, the presence of a high trait anxiety (OR=0.133, 95% CI;0.027-0.651) and motor disturbances (OR=3.517, 95% CI;1.098-11.267) were significantly associated with an increasing risk of poor outcome at the 1-month assessment. At the 3-month assessment, the presence of a high trait anxiety (OR=0.115, 95% CI;0.022-0.611) was the only prognostic factor. At the 6-month assessment, the presence of a high trait anxiety (OR=0.065, 95% CI;0.007-0.570) was the only significant prognostic factor.
... [2,3] The prevalence of sciatic symptoms reported in the literature varies considerably ranging from 1.6% in the general population to 43% in a selected working population. [4] Although the prognosis is good in most patients, [5] a substantial proportion (up to 30%) continues to have pain for 1 year or longer. [6,7] In approximately 90% of the cases, sciatica is caused by a herniated disc involving nerve root compression. ...
Sciatica is one of the causes of back pain. Sciatica equated with Gridhrasi in Ayurveda, caused by aggravated Vata dosha and mentioned under Vatavyadhi.
The study was conducted in 37 cases who registered in OPD & IPD of hospital presenting with classical features of Gridhrasi. The patients were divided randomly in two groups: Group-A, Karma Basti was planned in 21 patients with Vrishadi-Niruha Basti & Vajigandhadi Anuvasana-Basti and in Group-B, Karma Basti were planned in 16 patients with Vrishadi-Niruha Basti & Vajigandhadi Anuvasana-Basti after Vamana Karma.
Observations and findings were documented during study and evaluated by using various assessment criteria. Symptomatically & Statistically significant improvement (p<0.001) was observed in majority of cases. The results obtained indicated improvement in sign & symptoms of Gridhrasi and Karma Basti were effective in combating the disease. On comparing the overall effect of therapy, Group B was more effective than Group A. According to the Chikitsa Siddhanta, “Nadau Bastividhim kuryada yavadurdho na shudhyati” (Cakradutta) proved that Basti is more effective after Vamana in the management of Gridhrasi.
Keywords : Gridhrasi, Sciatica, Basti, Vamana Karma
... [3][4][5][6] Persistent or recurrent sciatica despite treatment leads to physical and emotional suffering for the patient and substantial costs in terms of treatment, sick leave, and pensions for society. 7,8 Magnetic resonance imaging (MRI), which is considered the imaging procedure of choice for patients in whom lumbar-disk herniation is suspected, 9,10 is frequently performed in patients with persistent or recurrent symptoms of sciatica. 11 However, the association between findings on MRI and symptoms is controversial, with several studies showing a high prevalence of disk herniation, ranging from 20 to 76%, in persons without any symptoms. ...
... 최근 우리 나 3) . 요통은 비스테로이 드항염증약(non-steroidal anti-inflammatory drugs, NSAIDs)을 위시한 약물치료가 가장 흔하며 다양한 치료법들이 있기는 하지만 확실하게 효과적인 치료법은 존재하지 않으 며 2) 수술이 다른 약물 치료나 운동치료 등 과 비교할 때 명확하게 우월하다는 근거 역 시 없다고 알려져 있다 [4][5][6] . 또한 요통에 대 한 치료비용이 증가한다고 해서 효과가 좋 은 것도 아니라는 보고가 있어서 7) 장기간의 의료사회적 부담이 큰 문제가 되는 상황이 다. 미국에서는 점차 많은 요통환자들이 서 양 의학적 치료에 만족하지 못하고 침이나 카이로프락틱(chiropractic technique) 등의 치료를 찾는 경향이 뚜렷이 증가하는 추세 를 보이며 8) , 2006년 9) . ...
Objective : To explore and describe chronic low back pain (cLBP) patients' experience of acupuncture treatment Methods : Eleven patients with cLBP who agreed and completed the informed consent to take part in this qualitative study were interviewed thoroughly and tape-recorded. Transcribed data were read independently by 4 researchers and analysed thematically with ground theory. Results : All participants chose acupuncture treatment for their cLBP because either they preferred, other people recommended, or felt conventional treatment being more comfortable. Most of the participants experienced improvement during acupuncture treatment and continued treatment motivated by mere expectations. Participants also expressed the specific physical responses/sensations to the effect of acupuncture; various adverse effects during the course of acupuncture treatment. Economic burden was another concern when combined with other therapies in Korean Medicine hospitals. It is considered as a specifically important to those who give acupuncture treatment to obtain a full treatment effect. Conclusions : The emotional facts that Korean patients with cLBP receiving acupuncture treatment benefited by the treatment and considering specific sensations from doctor-patient relationship were turned out to be important to have the maximum treatment effect. Findings from this study should be considered in both acupuncture research and practice.
Purpose
We aimed to compare the efficacy, safety, and cost-effectiveness of non-pharmacological- and pharmacological treatment strategies for Lumbar disc herniation (LDH) in pragmatic clinical settings.
Patients and Methods
This study was a pilot, two-armed, parallel pragmatic randomized controlled trial. Thirty patients aged 19–70 years with a numeric rating scale (NRS) score ≥5 for sciatica and confirmed LDH on magnetic resonance imaging (MRI) were included. Participants were assigned in a 1:1 ratio to non-pharmacological (non-Phm) or pharmacological (Phm) treatment group. They were treated for 8 weeks and a total follow-up period was 26 weeks after randomization. Non-Phm treatment included acupuncture, spinal manual therapy, etc., Phm included medication, injection, nerve block, etc., The primary outcome was a numeric rating scale (NRS) of radiating leg pain. NRS for low back pain, Oswestry disability index, visual analog scale, Fear-Avoidance Beliefs Questionnaire, patient global impression of change, Short Form-12 Health Survey, version 2, 5-level European Quality of Life-5 dimensions (EQ-5D) were also measured. Linear mixed model was used to evaluated the difference in change of outcomes from baseline between two groups. An economic evaluation was conducted using incremental cost-effectiveness ratios.
Results
There was no significant difference between the two groups in the intervention period, but non-Phm group showed significantly greater degree of improvement in follow-up of Week 14. Difference in the NRS for sciatica and ODI were 1.65 (95% CI 0.59 to 2.71, p=0.003) and 8.67 (95% CI 1.37 to 15.98, p=0.21), respectively in Week 14. The quality-adjusted life year (QALY) value calculated by EQ-5D and Short Form-6 Dimension were 0.006 (95% CI −0.012 to 0.024, p=0.472) and 0.015 (95% CI −0.008 to 0.038, p=0.195) higher in non-Phm group than in Phm group. The cost was lower in non-Phm group than in Phm group (Difference: −682, 95% CI −3349 to 1699, p=0.563).
Conclusion
We confirmed that the non-Phm treatment could be more cost-effective treatments than Phm treatments and feasibility of a large-scale of main study in future.
Introduction: The aim of this study is evaluting the results of disc restoration hidrogel implanted (GelstixTM) lomber disc hernia patients. Material-Method: Patients suffered from chronic back pain diagnosed lumber disc hernia who were admitted to Firat University Algology Clinic and treated with disc restoration hidrogel between January 2013 – January 2014 were evaluated. Cases were evaluated for demografic characteristics, magnetic resistance imaging findings, preoperative and postoperative VAS, complications, side effects and patients satisfaction after prosedure. Results: Of the operated 62 patients were 25 male (40,3%) and 37 female (59,7%). Mean age of all patients was 49,18±14,18 years, mean age of female patients was 50,81±13,37 years and mean age of male patients was 46,76±15,27 years. Mean duration of pain in female and male patients was 37,81±37,92 months and 25,36±33,58 months, respectively. Preoperative and postoperatif VAS scores of female and male patients were 8,24±1,09 and 7,88±1,01 and 3,56±2,11 and 3,76±2,17, respectively. Of the 62 patients suffered from 16 right leg pain (25,8%), 20 left leg pain (32,3%), 26 bilateral lower limb pain (41,9%). Of 62 patients 31 had no additional disorders (50%), 12 had cardiac disorders (19,4%), 3 had (4,8%) respiratory disorders, 7 had endocrine disorders (11,3%), 4 had both endocrine and cardiac disorders (6,5%), 2 had both cardiac and respiratory disorders (3,2%), 1 had both endocrine and respiratory disorders (1,6%), and 2 had both endocrine, cardiac and respiratory disorders (3,2%). Of the 62 patients 25 had bulging (40,3%), 5 had protrusion (8,1%), 4 had narrowed neural foramen (6,5%), 18 had bulging +narrowed neural foramen (29%), 3 had narrowed neural foramen + protrusion (4,8%) and 7 had bulging + protrusion (11,3%). Thirteen patients hadn’t had previous therapy (20,97%), transforaminal steroid injection was applied to 29 patients (46,77%) and medical threapy (such as NSAID, miyorelactants) was applied to 20 (32,26%). Levels of complaints were 2 at L2-L3 (3,2%), 17 at L3-L4 (27,4%), 28 at L4-L5 (45,2%) and 15 at L5-S1 (24,2%). Without L2-L3 level other operated levels had significant difference between preropeative VAS scores and postoperative VAS scores. The number of unsatissfied patients was 9 (14,5%), moderated satisfied patients number 16(25,8%),good satisfied patients number was 16 (25,8%), and perfectly satisfied patients number was 21 (33,9%). Conclusion: Disc restoration hidrogel is a safe minimal invasive technique with satisfactory results, low complication rates and low side effect risk especially in young and middle aged patients.
Lumbar disc herniation (LDH) is a major cause of sciatica. Emerging evidence indicated that inflammation induced by the herniated nucleus pulposus (NP) tissues plays a major role in the pathogenesis of sciatica. However, the underlying mechanisms are still elusive. Although microglia and macrophages have been implicated in nerve injury induced neuropathic pain, their roles in LDH induced sciatica largely remains unknown. This study successfully established and modified a mouse model of LDH. We found that nerve root compression using degenerated NP tissues can initiate remarkable and persistent sciatica, with increased and prolonged macrophage infiltration in dorsal root ganglions (DRGs) and significant activation of microglia in the spinal dorsal horn. Instead, compression of the nerve root with non-degenerated NP tissues only led to transient sciatica, with transient infiltration and activation of macrophages and microglia. Moreover, continuous treatment of PLX5622, a specific colony-stimulating factor 1 receptor (CSF1R) antagonist, ablated both macrophages and microglia, which effectively alleviated LDH induced sciatica. However, mechanical allodynia reoccurred along with the repopulation of macrophages and microglia after the withdrawal of PLX5622. Using RNA sequencing analysis, the current study depicted transcriptional profile changes of DRG after LDH and identified several macrophages-related potential target candidates. Our results suggested that microglia and macrophages may play an essential role in the development and maintenance of LDH induced sciatica. Targeting microglia and macrophages may be a promising treatment for chronic LDH induced sciatica.
Objective:
This meta-analysis evaluated surgical outcomes following endoscopic or conventional discectomy for recurrent lumbar disc herniation.
Methods:
Medline, Cochrane, EMBASE, and Google Scholar were search until October 16, 2016 using these terms: recurrent lumbar disc herniation, endoscopic surgery, and discectomy. Randomized controlled trials (RCTs), prospective, retrospective, and cohort studies were eligible for inclusion. Pooled difference in mean (PDM) with 95% confidence interval (CIs) or relative risks (RRs) were calculated using fixed-effects methods.
Results:
One RCT and 15 studies were included with a total of 820 patients. Patients received endoscopic surgery experienced shorter operation time than those received conventional surgery (PDM: -52.01, 95% CI: -76.84 to -27.18, P < 0.001). A significantly lower risk in complication was displayed in patients received endoscopic surgery compared to those received conventional surgery (RR: 0.209, 95% CI: 0.076-0.581, P = 0.003). No significant difference in the improvement in VAS (PDM: -2.19, 95% CI: -5.78 to 1.39, P = 0.231), length of stay (PDM: -6.44, 95% CI: -13.76 to 0.89, P = 0.085) and re-recurrence rate (PDM: 0.88, 95% CI: 0.22-3.50, P = 0.861) between groups.
Conclusions:
Endoscopic and conventional discectomy reduced patient pain comparably, but endoscopic discectomy had significantly lower operation time and lower risk in complications, which may impact other outcomes such as recovery and healthcare costs. More studies are needed to confirm our findings.
Supplementary information:
The online version contains supplementary material available at 10.1007/s43465-022-00636-1.
Objective
The aim of this study was to identify and describe clusters of patients with similar characteristics presenting with sciatica caused by a lumbar disc herniation in secondary care.
Methods
Forty-six percent (n=163) of the eligible patients (n=352) completed all questionnaires and were included in a hierarchical cluster analysis. The analysis was based on baseline characteristics for pain, pain awareness and catastrophizing, disability and quality of life (QOL). Clusters were compared for the use of pain medication, employment status and allocated treatment.
Results
Three significant clusters were identified.
Cluster 2 (n=49), coined the painfulness cluster, reported the lowest baseline characteristics for pain (>5) and disability together with a higher health-related QOL. Patients in cluster 3, labeled the painfulness and suffering cluster, had relatively high pain scores for back and leg pain (>6), high pain awareness and catastrophizing, i.e. suffering, but relatively limited disability and maintained QOL. Cluster 1 (n=71), the painfulness-suffering and disability cluster, was characterized by the most severe back and leg pain (>7), high pain awareness and catastrophizing with the lowest QOL and highest disability. Patients in cluster 1 underwent significantly more surgery and used the most extensive pain medication (WHO III).
Conclusion
This research gives insight in the complex population with sciatica and is of added value to the recent, sparsely existing literature on relevant patient subgroups in the low back and leg pain population. The data suggest that VAS scores <6 do not lead to suffering and VAS scores <7 not to disability.
Avaliar o perfil clínico, a melhora da dor e a necessidade de intervenções cirúrgicas em pacientes submetidos ao bloqueio transforaminal com uso de corticosteroides e anestésicos. Métodos: ensaio clínico randomizado e duplo-cego, com n=45, apresentando dor radicular unilateral em membros inferiores, tendo diagnóstico de hérnia discal lombar em único segmento. Ocorreu distribuição aleatória dos pacientes em dois grupos: o grupo intervenção e o grupo controle. Após, foram realizados bloqueios transforaminais com bupivacaína, dexametasona e clonidina no grupo intervenção, e no controle foi realizado o bloqueio com água destilada e bupivacaína. Além disso, foi aplicado o questionário de incapacidade de Oswestry no dia do procedimento e após uma e três semanas. Resultados: foram avaliados 45 pacientes, sendo 24 mulheres (53,4%) e 21 homens (46,6%). Dos pacientes que possuíam ocupação, 85,71% (n=30) estavam afastados de suas funções por conta da doença e 14,29% (n=5) continuavam a trabalhar, porém, referindo limitações. Avaliou-se que os pacientes que foram submetidos a bloqueio transforaminal com injeção de corticoide, clonidina e anestésico apresentam alívio imediato, mas após três semanas, esse efeito não perdura de forma tão satisfatória tendo apenas 52% dos pacientes apresentando melhora em graus variados. Já no grupo controle, houve discreto alívio álgico após uma semana, que não perdurou de forma satisfatória após três semanas, com 50% dos pacientes evoluindo para melhora em graus variados. Discussão: os resultados desse estudo sugerem um efeito positivo após uma e três semanas do bloqueio foraminal tanto com a solução contendo corticoide, clonidina e anestésico quanto com a solução contendo água destilada e anestésico. Esse resultado favorece a possibilidade de que a melhora nas primeiras semanas está relacionada ao uso de anestésico na solução e não ao uso do corticoide. Conclusões: Novos estudos com um espaço amostral maior, novos dados epidemiológicos e um seguimento mais prolongado serão necessários para validar as hipóteses aventadas.
Introduction. Radiculopathy is one of the causes of neuropathic pain. Among the causes of back pain, lumbar radiculopathy ranks second after non-specific musculoskeletal pain. Patients with radiculopathy have a marked decrease in the quality of life, a tendency to disability, which causes a large amount of diagnostic and therapeutic measures and associated economic losses. There is no unified view on the pathogenesis of radiculopathy, and the pain syndrome includes neuropathic and nociceptive components. The proposed treatment regimens for radiculopathy differ and are of a recommendatory nature.
The purpose of the retrospective observational study was to study the effectiveness of the drug Neurobion® in the complex therapy of radiculopathy.
Materials and methods . The study of outpatient records of 120 patients aged 25–65 years, suffering from lumbosacral radiculopathy was performed. The patients were divided into 2 groups and received basic therapy, which included NSAIDs, simple analgesics, muscle relaxants, and anticonvulsants. Patients of group 1 additionally received the drug Neurobion®.
Results and discussion . Faster regression of clinical manifestations was observed in group 1 patients. The results of treatment in group 1 patients were higher both in terms of subjective feelings and objective criteria. The presence of two medicinal forms of Neurobion® allows a personalized approach to the patient’s therapy
Conclusions. The use of the drug Neurobion® is pathogenetically justified in the treatment of radiculopathy, provides earlier positive dynamics of subjective feelings of patients and objective indicators, improves the quality of life, leads to shorter treatment periods, reducing economic costs. The effectiveness and good tolerability of the drug Neurobion® allow us to recommend it for inclusion in the complex therapy of radiculopathy.
Lumbar radiculopathy refers to a pathologic process involving the lumbar nerve roots. The prevalence of lumbar radiculopathy in the general population varies from 2.2% to 8%, depending on the study, and the incidence ranges from 0.7% to 9.6%. The most common symptom in lumbar radiculopathy is pain, which may vary in severity and location. The most important elements in the evaluation of lumbar radiculopathy are the history and physical examination. Diagnostic testing takes two forms: one to corroborate the diagnosis and the second to determine the etiology. Testing may include lumbosacral spine radiography, computed tomography scan, and magnetic resonance imaging. Electromyography and nerve conduction studies can be valuable in the diagnosis and prognosis of lumbar radiculopathy. The treatment goal is to reduce inflammation and thereby relieve the pain and allow resolution of the radiculopathy regardless of the underlying anatomic abnormalities. Treatment may include, nonsteroidal anti-inflammatory (NSAIDs), oral corticosteroids, epidural steroid injections, or surgical intervention.
Qualitative and quantitative assessment of the influence of various drugs upon spinal root microcirculation before and after spinal canal decompression in lumbar osteochondrosis was performed. Study included 87 (41 female and 46 male) patients aged 26 — 68 years with clinical manifestations of radiculopathy on the background of intervertebral disk hernia in lumbar osteochondrosis. All patients were operated on by Caspar technique. Indices of laser Doppler flowmetry in infrared channel were taken directly from the spinal nerve root before and after decompression. Patients from 1 st group (n=56) received no drugs. In patients from the 2 nd group (n=31) either euphyllinum (subgroup 2E), dexamethasone (subgroup 2D) or rheopolyglucin (subgroup 2R) were injected intravenously prior to decompression. All study drugs were effective and the most significant influence on the microcirculatory indices was exerted by rheopolyglucin. Initial index of microcirculation was 30 p.u. in 1 st group, 32 p.u. in subgroup 2E, 40 p.u. in subgroup 2D and 32p.u. in subgroup 2R. After decompression that index increased up to 36±6 p.u. in 1 st group and up to 40±8, 47±7, 44±12p.u. in three subgroups, respectively.
Study design:
Retrospective register study.
Objective:
The aim of this study was to assess the incidence and trends of lumbar disc surgeries in Finland from 1997 through 2018.
Summary of background data:
The evidence on lumbar spine discectomy has shifted from supporting surgical treatment toward nonoperative treatment. Still, the incidence of lumbar discectomy operations increased until the 1990 s. In the United States, the incidence began to decline after a downward turn in 2008, yet recent trends from countries with public and practically free health care are not widely known.
Methods:
Data for this study were obtained from the Finnish nationwide National Hospital Discharge Register. The study population covered all patients 18 years of age or older in Finland during a 22-year period from January 1, 1997, to December 31, 2018.
Results:
A total of 65,912 lumbar discectomy operations were performed in Finland from 1997 through 2018. The annual population-based incidence of lumbar discectomy decreased 29% during the 22-year period, from 83 per 100,000 person-years in 1997 to 58 per 100,000 person-years in 2018. In addition, the incidence of microdiscectomy increased 12%, from 41 per 100,000 person-years in 1997 to 47 per 100,000 person-years in 2018, whereas the incidence of open discectomy decreased 71%, from 41 per 100,000 person-years in 1997 to 12 per 100,000 person-years in 2018. The total reoperation rate for microendoscopic, microscopic, and open discectomy surgeries was 16.3%, 15.3%, and 14.9%, respectively.
Conclusion:
The nationwide incidence of lumbar discectomy decreased in Finland from 1997 through 2018. Additionally, the incidence of open discectomy is decreasing rapidly, whereas the incidence of microsurgical techniques is increasing.Level of Evidence: 3.
Vitamin D, a neurosteroid hormone, exerts its effects on the pain related to disc herniation, through changes in expression of inflammatory substances and pain modulators, number, and function of T helper 1, modulation in pain perception, and improvement of depression.
Background and objective: There is little information available on comparing conservative versus immediate surgery results in the long run for patients with lumbar disc herniation in the modern clinical practice. The aim of this study was to assess one-year outcomes of patients with sciatica resulting from a lumbar disc herniation treated surgically versus non-surgically in two hospitals in Erbil Methods: A prospective comparative cohort study was conducted over two years (January 2010 to February 2012). A sample 100 patients, 50 treated surgically and 50 conservatively, were followed up for one year. All participants had baseline interviews with follow-up questionnaires filled in the next specially designed follow up visits along the study time at regular intervals of 2, 8, 28 and 52 weeks. The outcome included patient-reported symptoms of leg and back pain, functional status, satisfaction versus expectation and working capacity after treatment or overall disability degree. Results: Change in the modified Roland back-specific functional status scale favored surgical treatment initially, and the relative benefit decreased but persisted over the follow-up period. Despite these differences, work and disability status at one year were comparable among those treated surgically or non-surgically. Conclusion: Surgically treated patients with a herniated lumbar disc had more complete relief of leg pain and improved function and satisfaction compared with non-surgically treated patients over one year. Nevertheless, improvement in the patient's predominant symptom and work and disability outcomes were closely similar regardless of treatment received
Objectives This study is planned to classify effectiveness of Korean medicine treatment on lumbar intervertebral Disc herniation patients` fear-avoidance belief. Methods We measured 84 patients with lumbar intervertebral disc herniation in Jaseng Korean Medicine Hospital. We used numeric rating scale, oswestry disability index, fear-avoidance belief questionaire for evaluating effectiveness of oriental medicine treatment on lumbar intervertebral disc herniation. And We used Magentic Resonance Imaging(MRI) for classifying the patient who has lumbar intervertebral disc or not. Results 1. There was statistical effectiveness of korean medicine treatment on lumbar intervertebral disc herniation patients` fear-avoidance belief (p and {\Delta}ODI (r
Background
Although both pregabalin and gabapentin are known to be useful for treating lumbar radiating pain and reducing the incidence of surgery, the oral corticosteroids sometimes offer a dramatic effect on severe radiating pain despite the lack of scientific evidence.
Methods
A total of 54 patients were enrolled among 703 patients who complained of lumbar radiating pain. Twenty patients who received an oral corticosteroid was classified as group A and 20 patients who received the control drugs (pregabalin or gabapentin) as group B. Oswestry Disability Index (ODI), Revised Roland Morris disability questionnaire (RMDQ), Short Form 36 (SF-36) questionnaire, lumbar radiating pain, objective patient satisfaction, and objective improvement of patients or physicians were assessed at 2, 6, and 12 weeks after medication.
Results
No difference in the sex ratio and age was observed between the groups (p = 0.70 and p = 0.13, respectively). Group A showed greater improvement in radiating pain after 2, 6, and 12 weeks than group B (p < 0.001, p = 0.001, and p < 0.001, respectively). No differences were observed between the groups in satisfaction at the beginning and 12 weeks after taking the medication (p = 0.062 and p = 0.061, respectively) and in objective improvement of patients and physicians (p = 0.657 and p = 0.748, respectively). Group A was less disabled and had greater physical health scores than group B (p = 0.014 and p = 0.017, respectively).
Conclusions
Oral corticosteroids for the treatment of lumbar radiating pain can be more effective in pain relief than gabapentin or pregabalin. The satisfaction of patients and physicians with the drug and objective improvement status were not inferior to that with gabapentin or pregabalin.
Study design:
Prospective observational 5-year study.
Objective:
To assess pain, functional disability, surgical status, and health care use of patients who actively selected complementary and alternative medicine treatment and risk factors for lumbar surgery.
Summary of background data:
Controversy continues regarding difference in long-term outcomes of conservative and surgical treatment.
Methods:
We recruited 150 consecutive lumbar disc herniation patients with radiating pain (numeric rating scale ≥5) from November, 2006 at a Korean medicine hospital outpatient department, of which 128 patients completed 6 months of complementary and alternative medicine treatment (herbal medicine, acupuncture, bee-venom pharmacopuncture, and Chuna manipulation). Follow-up data was collected every year for 5 years.
Results:
We assessed surgical status in 105 patients (82%), of which 8 replied that they had received surgery. Ninety-two patients (72%) attended the 5-year follow-up. Visual analog scale of back pain which was 4.19 ± 2.60 at baseline improved after treatment, decreasing to 0.94 ± 1.13 at 6 months, and was maintained at 1.25 ± 1.81 at 5 years. Visual analog scale of leg pain decreased from 7.50 ± 1.32 to 0.94 ± 1.29 and was sustained at 0.98 ± 1.73. Participants reported less disability with Oswestry Disability Index scores decreasing from 41.50 ± 15.07 at baseline to 11.24 ± 10.44 at 6 months, which then declined further to 7.61 ± 9.82 at 5 years. SF-36 quality-of-life health survey scores also improved, increasing from 33.41 ± 12.67 at baseline to 66.04 ± 15.77 at 6 months, and reaching 75.43 ± 15.79 at 5 years. In assessment of satisfaction with current state, 20% replied "highly satisfied," 67% "satisfied," 10% "fairly satisfied," and 2% "dissatisfied." Patients with younger age, previous treatment for current pain episode, and higher levels of sensory impairment and pain in the lower extremities were at higher risk of lumbar surgery.
Conclusion:
The long-term results of lumbar disc herniation patients receiving nonsurgical complementary and alternative medicine treatment were favorable and satisfaction rates were high.
Level of evidence:
2.
The aim of this open pilot observation was to prove the influence of the long-term oral systemic enzyme therapy (SE) on subjectively perceived pain, disabilities caused by back pain and development of late postoperative complications after lumbar disc herniation surgery. Patients after lumbar disc herniation surgery (n = 100; aver. age 41,99 year, SD ±9,06) were randomly divided into two groups. All patients were administered by analgesics and underwent physiotherapy after surgery. The SE group (n = 50, aver. age = 41,24 year, SD ±9,86) was administered by combined enzyme preparation Phlogenzym (bromelaina 90 mg, trypsinum 48 mg rutosid 100 mg), besides the usual post-operative treatment. The control group KO (n = 50, aver. age = 42,74 year, SD ±9,39) underwent obligatory treatment only. Preoperative and postoperative status was evaluated according to Visual Analog Scale (VAS), Roland-Morris questionnaire (RMQ) and Oswestry Disability Index (ODI). Subjective evaluation of improvement, development of failed back surgery syndrome (FBSS) and ability to work after surgery were other objectives of the follow-up. Statistical evaluation of the results was accomplished. Statistically significant differences between individual groups were proved for the benefit of the SE group in subjectively perceived pain (VAS, p = 0,025), disability for lower back pain (RMQ, p = 0,0006) and in the difference of the patients' disabilities in common daily activities (ODI, p = 0,023). The difference in late postoperative surgery complication occurrence was close to the significance level (p = 0,08). No difference in the influence of SE therapy on the ability to work (p = 0,68) was found. This follow-up results are stimulating for continuing research of SE as supportive treatment for patient after lumbar disc herniation surgery.
Background
Lumbar disc herniation is a major cause of sciatica and low back pain and imposes a heavy burden on both individual and society. While use of pharmacopuncture, a combined form of acupuncture and herbal medicine, for lumbar disc herniation is widespread in Korea and China, there is a paucity of research.
Methods/Design
This study is the protocol for a three-armed, randomized, patient, physician, and assessor-blinded controlled pilot study. Sixty patients with severe non-acute sciatic pain diagnosed with lumbar disc herniation (NRS ≥ 5, onset between 4 weeks and 6 months) will be recruited and randomized 20 each to the Shinbaro pharmacopuncture (pharmacopuncture with acupuncture), acupuncture, and usual care groups, respectively. The 2 acupuncture groups will receive 2 sessions/week of acupuncture alone or with pharmacopuncture for 4 weeks (total 8 sessions), and the usual care group will receive conventional medication 2–3 times/day and physical therapy 2 sessions/week over 4 weeks (total 8 sessions). The initial acupuncture physician will administer acupuncture at 5 acupoints (GB30, BL40, BL25, BL23, GB34) in the 2 acupuncture groups, and mark an additional acupoint. A second acupuncture physician will administer pharmacopuncture to the marked acupoint in the pharmacopuncture group, and acupuncture in the acupuncture group during acupuncture needle retention. The second physician will administer acupuncture and pharmacopuncture in a similar manner in terms of advice and manual stimulation to maintain patient-blinding, treat the patient out of view of the initial physician, remove the additional acupuncture needle immediately, and cover the area with adhesive bandage to maintain physician-blinding. The primary endpoint will be at 5 weeks post-randomization, and the primary outcome will be Visual Analog Scale (VAS) of sciatic pain. Secondary outcomes will be VAS of low back pain, Numeric Rating Scale (NRS) of low back pain and sciatic pain, ODI, SF-36, EQ-5D, and PGIC. Post-treatment evaluations will take place 5, 7, 9, and 12 weeks after randomization.
Discussion
This trial will evaluate the comparative clinical effectiveness of pharmacopuncture for severe non-acute sciatic pain patients diagnosed with lumbar disc herniation with usual care of conventional medicine and that of Korean medicine (acupuncture), monitor its safety, and serve as basis for a large-scale, multicenter trial.
Trial registration
ClinicalTrials.gov NCT02384928, registered 27 February 2015.
A 28-year-old man with no significant medical history presents to the spine clinic after sustaining a skiing-related injury. He jumped out of a helicopter to ski the back bowls of Vail and developed immediate lower back pain but was able to ski down the mountain. The same evening, he noticed radiating pain from the right lower back, buttock, and posterolateral thigh to the right calf. In addition he reported an antalgic gait and decreased toe push-off strength. The patient presents in the clinic 5 days after the onset of symptoms and reports near-complete resolution of pain with no bowel/bladder involvement, and he does not report getting any weaker. On examination, the patient has an absent right Achilles reflex. He is unable to complete 1 single-leg heel raise on the right, although he is able to dorsiflex his ankle and his extensor hallicus longus strength is 4/5. Magnetic resonance imaging (MRI) of the lumbar spine reveals a right L5-S1 paracentral disk extrusion compressing the S1 nerve root in the lateral recess, but relative sparing of the remainder of the spinal canal. At this point, what do you recommend: surgery or continued nonsurgical care? Drs Sayed Wahezi and Andrew Lederman will argue that this patient likely suffers from a self-limiting radi-culopathy and, with nonoperative care, should regain full function. Dr Eric H. Elowitz suggests that early operative management will deliver the greatest functional outcome in this case scenario.
This systematic review aims to assess the effectiveness and safety of acupuncture for treating sciatica.
The following nine databases will be searched from their inception to 30 October 2014: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), the Chinese Biomedical Literature Database (CBM), the Chinese Medical Current Content (CMCC), the Chinese Scientific Journal Database (VIP database), the Wan-Fang Database, the China National Knowledge Infrastructure (CNKI) and Citation Information by National Institute of Informatics (CiNii). Randomised controlled trials (RCTs) of acupuncture for sciatica in English, Chinese or Japanese without restriction of publication status will be included. Two researchers will independently undertake study selection, extraction of data and assessment of study quality. Meta-analysis will be conducted after screening of studies. Data will be analysed using risk ratio for dichotomous data, and standardised mean difference or weighted mean difference for continuous data.
This systematic review will be disseminated electronically through a peer-reviewed publication or conference presentations.
PROSPERO CRD42014015001.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
To investigate the efficacy of percutaneous chemonucleolysis using ethanol gel (PCEG) in alleviating radicular pain due to disc herniation after failure of conservative treatment.
After failure of conservative treatment, PCEG was performed under fluoroscopic guidance in 42 patients with sciatica >4/10 on a Visual Analog Scale (VAS) for at least 6 weeks and consistent disc herniation on MRI or CT <3 months. The VAS pain score was determined at baseline, then after 1 and 3 months. We assessed the influence of patient-related factors (age, gender, pain duration) and disc herniation-related factors (level, migration pattern, disc herniation-related spinal stenosis) on outcome of PCEG.
Mean pain duration was 6.7 months. Pain intensity decreased by 44 % and 62.6 % after 1 and 3 months, respectively, versus baseline (P = 0.007). A mild improvement was noted by the rheumatologist in 30/42 (71.4 %) and 36/42 (85.7 %) patients after 1 and 3 months, respectively, and in 31/42 (73.8 %) and 33/42 (78.6 %) patients by self-evaluation. Patients who failed PCEG were significantly older (49.8 vs. 37.3 years, P = 0.03). None of the other variables studied were significantly associated with pain relief.
PCEG may significantly improve disc-related radicular pain refractory to conservative treatment.
• Percutaneous chemonucleolysis using ethanol gel (PCEG) is feasible on an outpatient basis. • PCEG improves disc-related radicular pain refractory to conservative treatment. • PCEG is feasible on an outpatient basis. • Failure of PCEG does not interfere with subsequent spinal surgery.
Disc-related sciatica has a prevalence of about 2% in adults, but is rare in adolescents. If conservative treatment is unsuccessful, surgery is an option.
The aim of this study was to compare the outcomes of surgery for lumbar disc herniation in adolescents with adults in the SweSpine Register.
Prospective observational study. National Quality Register.
This study included 151 patients, aged 18 years or younger, 4,386 patients aged 19-39 years and 6,078 patients aged 40 years or older, followed for 1-2 years after surgery.
The primary outcomes were patient satisfaction and global assessment of back and leg pain. Secondary outcomes were visual analog scale (VAS) back pain, VAS leg pain, Oswestry Disability Index (ODI), and EuroQol 5-Dimensions (EQ-5D).
Financial support has been received from the Swedish Society of Spine Surgeons. Statistical analyses were performed with the Welch F-test, the Chi-square test, and the Wilcoxon test.
At follow-up, 86% of the adolescents were satisfied compared to 78% in the younger adults and 76% in the older adults group (p<0.001). According to the global assessment, significantly decreased leg pain was experienced by 87% of the adolescents, 78% of the younger adults and 71% of the older adults (p<0.001). Corresponding figures for back pain were 88%, 73% and 70%, respectively (p<0.001). All groups experienced significant post-operative improvement of VAS leg pain, VAS back pain, ODI and EQ-5D (all p<0.001).
The adolescent age group was more satisfied with the treatment than the adult groups. There was a significant improvement in all age groups after surgery.
Copyright © 2015 Elsevier Inc. All rights reserved.
Objective was to evaluate the efficacy of outpatient rehabilitation and to determine factors that influence it in patients with disorders of the lumbosacral plexus. Methods. The research was performed in two stages. The outpatient rehabilitation medical records data of 280 patients with lumbosacral plexus disorders were analyzed retrospectively in the first stage. Rehabilitation efficacy was evaluated according to decrease in pain intensity. Prospective analysis of the outpatient rehabilitation efficacy was performed in the second stage. 39 patients with disorders of the lumbosacral plexus were examined using 0-10 Numeric Rating Scale, Roland Morris Disability Questionnaires (RMDQ) for low back and separate for leg (RMDQ-L) and the Brief ICF Core Set for Low Back Pain, at the start and the end of rehabilitation. Results. Retrospective study determined the average score of reduction in pain intensity was 2.7, (p<0.05). Pain decrease varied significantly in men and women groups. For patients with sensation disorders average reduction in pain intensity was less if compared to the patients without sensation disorders. Univariate logistic regression model was applied for the evaluation of sociodemographic factors, clinical data on the decrease of pain intensity. It was determined, that female gender (odds ratio -2.1 ( 95% CI 1.2-3.8, p=0.02), the absence of intervertebral disc herniation (odds ratio -2.5 ( 95% CI 1.0- 6.3, p=0.04), worst possible pain (9-10 points) (odds ratio -5.4; 95% CI 1.2-24.4, p=0.02) and severe pain (6-8 points) before rehabilitation (odds ratio -1.8; 95% CI 1.0-3.2, p=0.02) had the greatest importance in pain intensity decrease in 2 and more points. The prospective study determined the average score of reduction in low back pain intensity was 2.8, in leg pain – 2.5, disability level in RMDQ– 4.3, RMDQ-L– 3.7, (p<0.001). Reduction in low back pain was significantly related with return to work, (p<0.001), 60% of the researched employed people returned to work after rehabilitation. The status of patients evaluation according to ICF helped to identify the most significant problems and to determine patients environmental factors. Conclusion. Outpatient rehabilitation for patients with disorders of the lumbosacral plexus significantly reduces pain and disability. Reduction in pain was more in patients who complained about greater pain before rehabilitation. Male gender, diagnosed intervertebral disc herniation and sensation disorders are negative factors of rehabilitation efficacy. Patient state evaluation according to ICF helps to set the greatest problems of the patients not only according to the medical, but also according to the biopsychosocial approach.
Article in Lithuanian
doi:10.5200/sm-hs.2012.117
Aim:
To assess the short and medium-term efficacy and safety of a novel, minimally invasive therapeutic option combining automated percutaneous lumbar discectomy, intradiscal ozone injection, and caudal epidural: ozone-augmented percutaneous discectomy (OPLD).
Materials and methods:
One hundred and forty-seven patients with a clinical and radiological diagnosis of discogenic sciatica who were refractory to initial therapy were included. Fifty patients underwent OPLD whilst 97 underwent a further caudal epidural. Outcomes were evaluated using McNab's score, improvement in visual analogue score (VAS) pain score, and requirement for further intervention. Follow-up occurred at 1 and 6 months, and comparison was made between groups.
Results:
OPLD achieved successful outcomes in almost three-quarters of patients in the short and medium term. OPLD achieved superior outcomes at 1 and 6 months compared to caudal epidural. There was a reduced requirement for further intervention in the OPLD group. No significant complications occurred in either group.
Discussion:
OPLD is a safe and effective treatment for patients with refractory discogenic sciatica in the short and medium term. OPLD has the potential to offer an alternative second-line minimally invasive treatment option that could reduce the requirement for surgery in this patient cohort.
Background
It is common in medical practice to see patients having persistent pain and radiculopathy even after undergoing discectomy surgery. Inflammatory cytokines, such as interleukins are produced at the site of disc herniation and are now considered responsible for the pain perceived by the patient. This study has used high sensitive C-reactive protein (HSCRP) assay for predicting inflammation around the nerve roots on very same principle, which has used HSCRP for predicting coronary artery diseases in current clinical practice. Thus, purpose of this study is to test whether HSCRP can stand as an objective tool to predict postoperative recovery in patients undergoing lumbar discectomy. That is, to study association between preoperative HSCRP blood level and postoperative recovery with the help of modified Oswestry Back Disability Score.Materials and MethodsA study group consisting of 50 cases of established lumbar disc disease and control group of 50 normal subjects, matched with the study group. Both the study and control groups were subjected to detailed evaluation with the help of modified Oswestry Low Back Pain Scale both pre and postoperatively at 3 months, 6 months and 1-year. The preoperative blood samples were analyzed to assess the HSCRP concentration. All the cases underwent surgery over a period of 1-year by the same surgeon.ResultsThe level of HSCRP in the study group was between 0.050–and 0.710 mg/dL and in the control group, 0.005-0.020 mg/dL. There was highly significant positive correlation between preoperative HSCRP level and postoperative score at P < 0.005. Cases with HSCRP level in the range of 0.1820 ± 0.079 mg/dL, showed better recovery (score improved > 10 points), while those with HSCRP level in the range of 0.470 ± 0.163 mg/dL, showed poor recovery (score improved < 10 points).ConclusionHSCRP will serve as a good supplementary prognostic marker for operative decision making in borderline and troublesome cases of lumbar disc disease.
Epidural steroid injection is the most frequently performed pain procedure. This study of epidural steroid "control" injections aimed to determine whether epidural nonsteroid injections constitute a treatment or true placebo in comparison with nonepidural injections for back and neck pain treatment.
This systematic review with direct and indirect meta-analyses used PubMed and EMBASE searches from inception through October 2012 without language restrictions. Study selection included randomized controlled trials with a treatment group receiving epidural injections of corticosteroids or another analgesic and study control groups receiving either an epidural injection devoid of treatment drug or a nonepidural injection. Two reviewers independently extracted data including short-term (up to 12 weeks) pain scores and pain outcomes. All reviewers evaluated studies for eligibility and quality.
A total of 3,641 patients from 43 studies were included in this systematic review and meta-analysis. Indirect comparisons suggested epidural nonsteroid were more likely than nonepidural injections to achieve positive outcomes (risk ratio, 2.17; 95% CI, 1.87-2.53) and provide greater pain score reduction (mean difference, -0.15; 95% CI, -0.55 to 0.25). In the very limited direct comparisons, no significant differences were noted between epidural nonsteroid and nonepidural injections for either outcome (risk ratio [95% CI], 1.05 [0.88-1.25]; mean difference [95% CI], 0.22 [-0.50 to 0.94]).
Epidural nonsteroid injections may provide improved benefit compared with nonepidural injections on some measures, though few, low-quality studies directly compared controlled treatments, and only short-term outcomes (≤12 weeks) were examined.
This thesis is about effectiveness of surgical interventions in the spine and the value of different methodologies for providing a valid answer.
In the first part five systematic reviews were performed. One reviewed cervical degenerative disc disease comparing the different anterior fusion techniques. Two were performed on lumbar disc herniation comparing conservative interventions with surgical and comparing the several surgical techniques. One was on lumbar degenerative disc disease and evaluated disc replacement. The fifth evaluated interventions for low grade lumbar isthmic spondylolisthesis.
In the second part systematic reviews were searched, selected and appraised in two meta-epidemiological studies. Spinal research suffers from specific problems with regard to randomization and related to that, blinding and allocation concealment. These are factors that have in other medical fields been shown to introduce biased results. Our studies showed that observational studies in spinal surgery research do not result in an overestimation of the treatment effect in contrast to other medical disciplines.
Finally, the experience gained from these studies has resulted in several opinion papers that aim to guide the scientific field in using the most appropriate methods in spine surgery research.
Context Lumbar diskectomy is the most common surgical procedure performed for back and leg symptoms in US patients, but the efficacy of the procedure relative to nonoperative care remains controversial.Objective To assess the efficacy of surgery for lumbar intervertebral disk herniation.Design, Setting, and Patients The Spine Patient Outcomes Research Trial, a randomized clinical trial enrolling patients between March 2000 and November 2004 from 13 multidisciplinary spine clinics in 11 US states. Patients were 501 surgical candidates (mean age, 42 years; 42% women) with imaging-confirmed lumbar intervertebral disk herniation and persistent signs and symptoms of radiculopathy for at least 6 weeks.Interventions Standard open diskectomy vs nonoperative treatment individualized to the patient.Main Outcome Measures Primary outcomes were changes from baseline for the Medical Outcomes Study 36-item Short-Form Health Survey bodily pain and physical function scales and the modified Oswestry Disability Index (American Academy of Orthopaedic Surgeons MODEMS version) at 6 weeks, 3 months, 6 months, and 1 and 2 years from enrollment. Secondary outcomes included sciatica severity as measured by the Sciatica Bothersomeness Index, satisfaction with symptoms, self-reported improvement, and employment status.Results Adherence to assigned treatment was limited: 50% of patients assigned to surgery received surgery within 3 months of enrollment, while 30% of those assigned to nonoperative treatment received surgery in the same period. Intent-to-treat analyses demonstrated substantial improvements for all primary and secondary outcomes in both treatment groups. Between-group differences in improvements were consistently in favor of surgery for all periods but were small and not statistically significant for the primary outcomes.Conclusions Patients in both the surgery and the nonoperative treatment groups improved substantially over a 2-year period. Because of the large numbers of patients who crossed over in both directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis.Trial Registration clinicaltrials.gov Identifier: NCT00000410
Patients with a lumbosacral radicular syndrome are mostly treated conservatively first. The effect of the conservative treatments remains controversial. To assess the effectiveness of conservative treatments of the lumbosacral radicular syndrome (sciatica). Relevant electronic databases and the reference lists of articles up to May 2004 were searched. Randomised clinical trials of all types of conservative treatments for patients with the lumbosacral radicular syndrome selected by two reviewers. Two reviewers independently assessed the methodological quality and the clinical relevance. Because the trials were considered heterogeneous we decided not to perform a meta-analysis but to summarise the results using the rating system of levels of evidence. Thirty trials were included that evaluated injections, traction, physical therapy, bed rest, manipulation, medication, and acupuncture as treatment for the lumbosacral radicular syndrome. Because several trials indicated no evidence of an effect it is not recommended to use corticosteroid injections and traction as treatment option. Whether clinicians should prescribe physical therapy, bed rest, manipulation or medication could not be concluded from this review. At present there is no evidence that one type of treatment is clearly superior to others, including no treatment, for patients with a lumbosacral radicular syndrome.
Bed rest is widely advocated for sciatica, but its effectiveness has not been established. To study the effectiveness of bed rest in patients with a lumbosacral radicular syndrome of sufficient severity to justify treatment with bed rest for two weeks, we randomly assigned 183 subjects to either bed rest or watchful waiting for this period. The primary outcome measures were the investigator's and patient's global assessments of improvement after 2 and 12 weeks, and the secondary outcome measures were changes in functional status and in pain scores (after 2, 3, and 12 weeks), absenteeism from work, and the need for surgical intervention. Neither the investigators who assessed the outcomes nor those involved in data entry and analysis were aware of the patients' treatment assignments.
After two weeks, 64 of the 92 patients in the bed-rest group (70 percent) reported improvement, as compared with 59 of the 91 patients in the control (watchful-waiting) group (65 percent) (adjusted odds ratio for improvement in the bed-rest group, 1.2; 95 percent confidence interval, 0.6 to 2.3). After 12 weeks, 87 percent of the patients in both groups reported improvement. The results of assessments of the intensity of pain, the bothersomeness of symptoms, and functional status revealed no significant differences between the two groups. The extent of absenteeism from work and rates of surgical intervention were similar in the two groups.
Among patients with symptoms and signs of a lumbosacral radicular syndrome, bed rest is not a more effective therapy than watchful waiting.
A systematic review of randomized and nonrandomized controlled trials.
Lumbar supports are used in the treatment of low back pain, but also to prevent the onset (primary prevention) or recurrences of a low back pain episode (secondary prevention).
To assess the effects of lumbar sup-ports for prevention and treatment of nonspecific low back pain.
The Medline, Cinahl, and Current Contents databases; the Cochrane Controlled Trials Register up to September 1999; and the Embase database up to September 1998 were all searched. References of identified trials and systematic reviews were reviewed and the Science Citation Index used to identify additional trials. Methodologic quality assessment and data extraction were performed by two reviewers independently. A quantitative analysis was performed in which the strength of evidence was classified as strong, moderate, limited or conflicting, and no evidence.
Five randomized and two nonrandomized preventive trials and six randomized therapeutic trials were included in the review. Only 4 of the 13 studies were of high quality. There was moderate evidence that lumbar supports are not effective for primary prevention. No evidence was found on the effectiveness of lumbar supports for secondary prevention. The systematic review of therapeutic trials showed that there is limited evidence that lumbar supports are more effective than no treatment, whereas it is still unclear whether lumbar supports are more effective than other interventions for treatment of low back pain.
There continues to be a need for high quality randomized trials on the effectiveness of lumbar supports. One of the most essential issues to tackle in these future trials seems to be the realization of adequate compliance.
Oxygen-ozone therapy is a minimally invasive treatment for lumbar disk herniation that exploits the biochemical properties of a gas mixture of oxygen and ozone. We assessed the therapeutic outcome of oxygen-ozone therapy and compared the outcome of administering medical ozone alone with the outcome of medical ozone followed by injection of a corticosteroid and an anesthetic at the same session.
Six hundred patients were treated with a single session of oxygen-ozone therapy. All presented with clinical signs of lumbar disk nerve root compression, with CT and/or MR evidence of contained disk herniation. Three hundred patients (group A) received an intradiscal (4 mL) and periganglionic (8 mL) injection of an oxygen-ozone mixture at an ozone concentration of 27 micro g/mL. The other 300 patients (group B) received, in addition, a periganglionic injection of corticosteroid and anesthetic. Therapeutic outcome was assessed 6 months after treatment by using a modified MacNab method. Results were evaluated by two observers blinded to patient distribution within the two groups.
A satisfactory therapeutic outcome was obtained in both groups. In group A, treatment was a success (excellent or good outcome) in 70.3% and deemed a failure (poor outcome or recourse to surgery) in the remaining 29.7%. In group B, treatment was a success in 78.3% and deemed a failure in the remaining 21.7%. The difference in outcome between the two groups was statistically significant (P <.05).
Combined intradiscal and periganglionic injection of medical ozone and periganglionic injection of steroids has a cumulative effect that enhances the overall outcome of treatment for pain caused by disk herniation. Oxygen-ozone therapy is a useful treatment for lumbar disk herniation that has failed to respond to conservative management.
To determine the efficacy of epidural corticosteroid injections for sciatica.
Three epidural injections (two day intervals) of 2 ml prednisolone acetate (50 mg) or 2 ml isotonic saline were administered to patients with sciatica presumably due to a disk herniation lasting 15-180 days. Self evaluation was the main judgment criterion at day 20. Patients who recovered or showed marked improvement were considered as success. Pain measured by VAS, the SLR test, Schober's test, Dallas pain questionnaire, and the Roland-Morris index were evaluated at days 0, 5, 20, and 35. Only analgesics were authorised, patients requiring non-steroidal anti-inflammatory drugs (NSAIDs) before day 20 were considered as failure.
42 patients were included in the control group (CG), 43 in the steroid group (SG). On an intention to treat analysis 15/42 (36%) in the CG and 22/43 (51%) in the SG (p=0.15) were considered as success (difference 15.5%, 95% CI (-5.4 to 36.3)). Among the 48 failures, 14 patients (6 CG, 8 SG) required NSAIDs, 3 (2 CG, 1 SG) required surgery, and 7 (3 CG, 4 SG) other treatments. On analysis according to protocol, in 74 remaining patients 12/35 (34%) in the CG and 22/39 (56%) in the SG (p=0.057) were considered as success (difference 22.1%, 95% CI (0.0 to 44.2)). For all secondary end points intragroup improvement with time was significant, but intergroup differences were not.
The efficacy of isotonic saline administered epidurally for sciatica cannot be excluded, but epidural steroid injections provide no additional improvement.
For patients with lumbar disk herniation, the Spine Patient Outcomes Research Trial (SPORT) randomized trial intent-to-treat analysis showed small but not statistically significant differences in favor of diskectomy compared with usual care. However, the large numbers of patients who crossed over between assigned groups precluded any conclusions about the comparative effectiveness of operative therapy vs usual care.
To compare the treatment effects of diskectomy and usual care.
Prospective observational cohort of surgical candidates with imaging-confirmed lumbar intervertebral disk herniation who were treated at 13 spine clinics in 11 US states and who met the SPORT eligibility criteria but declined randomization between March 2000 and March 2003.
Standard open diskectomy vs usual nonoperative care.
Changes from baseline in the Medical Outcomes Study Short-Form Health Survey (SF-36) bodily pain and physical function scales and the modified Oswestry Disability Index (American Academy of Orthopaedic Surgeons/MODEMS version).
Of the 743 patients enrolled in the observational cohort, 528 patients received surgery and 191 received usual nonoperative care. At 3 months, patients who chose surgery had greater improvement in the primary outcome measures of bodily pain (mean change: surgery, 40.9 vs nonoperative care, 26.0; treatment effect, 14.8; 95% confidence interval, 10.8-18.9), physical function (mean change: surgery, 40.7 vs nonoperative care, 25.3; treatment effect, 15.4; 95% CI, 11.6-19.2), and Oswestry Disability Index (mean change: surgery, -36.1 vs nonoperative care, -20.9; treatment effect, -15.2; 95% CI, -18.5. to -11.8). These differences narrowed somewhat at 2 years: bodily pain (mean change: surgery, 42.6 vs nonoperative care, 32.4; treatment effect, 10.2; 95% CI, 5.9-14.5), physical function (mean change: surgery, 43.9 vs nonoperavtive care 31.9; treatment effect, 12.0; 95% CI; 7.9-16.1), and Oswestry Disability Index (mean change: surgery -37.6 vs nonoperative care -24.2; treatment effect, -13.4; 95% CI, -17.0 to -9.7).
Patients with persistent sciatica from lumbar disk herniation improved in both operated and usual care groups. Those who chose operative intervention reported greater improvements than patients who elected nonoperative care. However, nonrandomized comparisons of self-reported outcomes are subject to potential confounding and must be interpreted cautiously.
clinicaltrials.gov Identifier: NCT00000410.
Lumbar diskectomy is the most common surgical procedure performed for back and leg symptoms in US patients, but the efficacy of the procedure relative to nonoperative care remains controversial.
To assess the efficacy of surgery for lumbar intervertebral disk herniation.
The Spine Patient Outcomes Research Trial, a randomized clinical trial enrolling patients between March 2000 and November 2004 from 13 multidisciplinary spine clinics in 11 US states. Patients were 501 surgical candidates (mean age, 42 years; 42% women) with imaging-confirmed lumbar intervertebral disk herniation and persistent signs and symptoms of radiculopathy for at least 6 weeks.
Standard open diskectomy vs nonoperative treatment individualized to the patient.
Primary outcomes were changes from baseline for the Medical Outcomes Study 36-item Short-Form Health Survey bodily pain and physical function scales and the modified Oswestry Disability Index (American Academy of Orthopaedic Surgeons MODEMS version) at 6 weeks, 3 months, 6 months, and 1 and 2 years from enrollment. Secondary outcomes included sciatica severity as measured by the Sciatica Bothersomeness Index, satisfaction with symptoms, self-reported improvement, and employment status.
Adherence to assigned treatment was limited: 50% of patients assigned to surgery received surgery within 3 months of enrollment, while 30% of those assigned to nonoperative treatment received surgery in the same period. Intent-to-treat analyses demonstrated substantial improvements for all primary and secondary outcomes in both treatment groups. Between-group differences in improvements were consistently in favor of surgery for all periods but were small and not statistically significant for the primary outcomes.
Patients in both the surgery and the nonoperative treatment groups improved substantially over a 2-year period. Because of the large numbers of patients who crossed over in both directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis.
clinicaltrials.gov Identifier: NCT00000410.
The evidence suggests that traction is probably not effective. For patients with a mixed duration of low-back pain (LBP), with or without sciatica, continuous or intermittent traction by itself was no more effective than placebo, sham or other treatments in improving pain, function or work absenteeism. In studies that examined only patients with sciatica, the evidence was inconsistent as to whether continuous or intermittent traction was more effective than placebo, sham or other treatments for improving pain and function. There was moderate evidence that autotraction was more effective than mechanical traction for global improvement in the same population. This review included 24 RCTs, and 2177 patients with a mix of acute, sub-acute or chronic LBP, with or without sciatica. Traction was compared to placebo, sham, no treatment, or other treatments. Different types of traction were examined by themselves or as part of a multi-treatment program.
Lumbar-disk surgery often is performed in patients who have sciatica that does not resolve within 6 weeks, but the optimal timing of surgery is not known.
We randomly assigned 283 patients who had had severe sciatica for 6 to 12 weeks to early surgery or to prolonged conservative treatment with surgery if needed. The primary outcomes were the score on the Roland Disability Questionnaire, the score on the visual-analogue scale for leg pain, and the patient's report of perceived recovery during the first year after randomization. Repeated-measures analysis according to the intention-to-treat principle was used to estimate the outcome curves for both groups.
Of 141 patients assigned to undergo early surgery, 125 (89%) underwent microdiskectomy after a mean of 2.2 weeks. Of 142 patients designated for conservative treatment, 55 (39%) were treated surgically after a mean of 18.7 weeks. There was no significant overall difference in disability scores during the first year (P=0.13). Relief of leg pain was faster for patients assigned to early surgery (P<0.001). Patients assigned to early surgery also reported a faster rate of perceived recovery (hazard ratio, 1.97; 95% confidence interval, 1.72 to 2.22; P<0.001). In both groups, however, the probability of perceived recovery after 1 year of follow-up was 95%.
The 1-year outcomes were similar for patients assigned to early surgery and those assigned to conservative treatment with eventual surgery if needed, but the rates of pain relief and of perceived recovery were faster for those assigned to early surgery. (Current Controlled Trials number, ISRCTN26872154 [controlled-trials.com].).
In recent years, convincing evidence has emerged implicating tumor necrosis factor alpha as a causative factor in radiculopathy and discogenic back pain. But although preliminary open-label studies demonstrated promising results for the treatment of low back pain with tumor necrosis factor-alpha inhibitors, early optimism has been tainted by a controlled study showing no significant benefit in sciatica. To determine whether outcomes might be improved by a more direct route of administration, the authors evaluated escalating doses of intradiscal etanercept in 36 patients with chronic lumbosacral radiculopathy or discogenic low back pain.
A double-blind, placebo-controlled pilot study was conducted whereby six patients received 0.1, 0.25, 0.5, 0.75, 1.0, or 1.5 mg etanercept intradiscally in each pain-generating disc. In each escalating dose group of six patients, one received placebo. A neurologic examination and postprocedure leukocyte counts were performed in all patients at 1-month follow-up visits. In patients who experienced significant improvement in pain scores and function, follow-up visits were conducted 3 and 6 months after the procedure.
At 1-month follow-up, no differences were found for pain scores or disability scores between or within groups for any dose range or subgroup of patients. Only eight patients remained in the study after 1 month and elected to forego further treatment. No complications were reported, and no differences were noted between preprocedure and postprocedure leukocyte counts.
Although no serious side effects were observed in this small study, a single low dose of intradiscal etanercept does not seem to be an effective treatment for chronic radicular or discogenic low back pain.
Two hundred eighty patients with herniated lumbar discs, verified by radiculography, were divided into three groups. One group, which mainly will be dealt with in this paper, consisted of 126 patients with uncertain indication for surgical treatment, who had their therapy decided by randomization which permitted comparison between the results of surgical and conservative treatment. Another group comprising 67 patients had symptoms and signs that beyond doubt, required surgical therapy. The third group of 87 patients was treated conservatively because there was no indication for operative intervention. Follow-up examinations in the first group were performed after one, four, and ten years. The controlled trial showed a statistically significant better result in the surgically treated group at the one-year follow-up examination. After four years the operated patients still showed better results, but the difference was no longer statistically significant. Only minor changes took place during the last six years of observation.
Study Design. A randomized controlled trial. Objectives. To evaluate the efficacy of infliximab, a monoclonal antibody against tumor necrosis factor (TNF)-α in a randomized controlled setting. Summary of Background Data. Recently, we obtained encouraging results in an open-label study of infliximab in patients with disc herniation-induced sciatica. Furthermore, the results of experimental studies support the use of infliximab in sciatica. Therefore, we initiated a randomized, controlled trial (FIRST II, Finnish Infliximab Related STudy) to confirm the efficacy of a single infusion of infliximab for sciatic pain. Methods. Inclusion criteria were unilateral moderate to severe sciatic pain with an MRI-confirmed disc herniation concordant with the symptoms and signs of radicular pain. Patients had to be candidates for discectomy, as evaluated by an independent orthopedic surgeon. Forty patients were allocated to a single intravenous infusion of either infliximab 5 mg/kg or placebo. Assessments at baseline and various time points included clinical examination with measurement of straight leg raising restriction; questionnaires related to subjective symptoms (leg and back pain by 100-mm visual analog scale, Oswestry disability); sick leaves; number of discectomies; and adverse effects possibly related to treatment. The primary endpoint was a reduction in leg pain from baseline to 12 weeks, which was analyzed using a Mann-Whitney U test and repeated-measures analysis. Results. A significant reduction in leg pain was observed in both groups, with no significant difference between treatment regimens. Similar efficacy was observed between treatment groups for secondary endpoints. Seven patients in each group required surgery. No adverse effects related to treatment were encountered. Conclusions. The results of this randomized trial do not support the use of infliximab for lumbar radicular pain in patients with disc herniation-induced sciatica.
Two hundred eighty patients with herniated lumbar discs, verified by radiculography, were divided into three groups. One group, which mainly will be dealt with in this paper, consisted of 126 patients with uncertain indication for surgical treatment, who had their therapy decided by randomization which permitted comparison between the results of surgical and conservative treatment. Another group comprising 67 patients had symptoms and signs that beyond doubt, required surgical therapy. The third group of 87 patients was treated conservatively because there was no indication for operative intervention. Follow-up examinations in the first group were performed after one, four, and ten years. The controlled trial showed a statistically significant better result in the surgically treated group at the one-year follow-up examination. After four years the operated patients still showed better results, but the difference was no longer statistically significant. Only minor changes took place during the last six years of observation.
A randomized clinical trial was conducted to compare the results of automated percutaneous discectomy with those of chemonucleolysis in 141 patients with sciatica caused by a disk herniation; 69 underwent automated percutaneous discectomy and 72 were subjected to chemonucleolysis. The principle outcome was the overall assessment of the patient 6 months after treatment. Treatment was considered to be successful by 61% of the patients in the chemonucleolysis group compared with 44% in the automated percutaneous discectomy group. At 1-year follow-up, overall success rates were 66% in the chemonucleolysis group and 37% in the automated percutaneous group. Within 6 months of treatment, 7% of the patients in the chemonucleolysis group and 33% in the discectomy group underwent subsequent open surgery. The complication rates of both treatment groups were low, with the exception of a high rate of low-back pain in the chemonucleolysis group (42%). The results of this trial confirm previous controlled studies on chemonucleolysis and suggest that controlled studies should be carried out before automated percutaneous discectomy can be considered a useful intervention.
The authors conducted a study to compare the efficacies of three nonsurgical treatment strategies in patients with sciatica. Their hypothesis was that bed rest, physiotherapy, and continuation of activities of daily living (ADLs) (control treatment) are each of equivalent efficacy.
This randomized controlled trial was designed for comparison of bed rest, physiotherapy, and continuation of ADLs. The setting was an outpatient clinic. General practitioners were asked to refer patients for treatment as soon as possible. The authors enrolled 250 patients (< 60 years of age) with sciatica of less than 1-month's duration and who had not yet been treated with bed rest or physiotherapy. Primary outcome measures were radicular pain (based on a visual analog pain scale [VAPS]) and hampered ADLs (Quebec Disability Scale [QDS]). Secondary outcome measures were the rates of treatment-related failure and surgical treatment. Measures were assessed at baseline and during follow up at 1, 2, and 6 months. Mean differences in VAPS and QDS scores between bed rest and control treatment were 2.5 (95% confidence interval [CI] -6.4 to 11.4) and -4.8 (95% CI -10.6 to 0.9) at 1 month and 0.9 (95% CI -8.7 to 10.4) and -2.7 (95% CI -9.9 to 4.4) at 2 months, respectively. The respective differences between physiotherapy and control treatment were 0.8 (95% CI -8.2 to 9.8) and -0.5 (95% CI -6.3 to 5.3) at 1 month and -0.3 (95% CI -9.4 to 10) and 0.0 (95% CI -7.2 to 7.3) at 2 months. The respective odds ratios for treatment failure and surgical treatment of bed rest compared with control treatment were 1.6 (95% CI 0.8-3.5) and 1.5 (95% CI 0.7-3.6) at 6 months. When physiotherapy was compared with control treatment, these ratios were 1.5 (95% CI 0.7-3.2) and 1.2 (95% CI 0.5-2.9) at 6 months, respectively.
Bed rest and physiotherapy are not more effective in acute sciatica than continuation of ADLs.
To demonstrate the efficiency of the treatment of the lumbar disk herniation (LDH) with absolute alcohol.
From June 1997 to September 2000, 118 patients with 126 LDH, 69 males and 49 females, aged 19 to 77 (mean age: 51.1 years) were treated with absolute alcohol nucleolysis. In 75 cases, the LDH were parasagittal, in 30 foraminal, in 17 medial and in 4 extraforaminal. In most cases, the sensitive symptoms and motor or reflex abnormalities corresponded to the lumbar disc herniation level. Nucleolysis was made in ambulatory condition and each patient underwent general anesthesia. All procedures were performed in surgical conditions and controlled under digital fluoroscopy. The disc puncture was laterally made at the junction of middle and posterior thirds of the disc, under strict lateral fluoroscopic control. A discogram was obtained before ethanol injection. Injection dose of absolute alcohol was 0.4 ml. The realization time was about 15 minutes.
Total improvement of symptoms was obtained in 97.55% of cases. Two patients remained with low-back pain and the failure treatment rate was 0.84% (1 case).
Nucleolysis with ethanol is a very effective, safe and low cost treatment for any kind of LDH, that allows to treat several levels during the same procedure, and can be repeated several times. Nucleolysis with ethanol can be made in ambulatory condition and be proposed to patients who refuse surgical treatment and have allergic background.
Although the existence of a motor defect in discogenic sciatica is a sign of severity, the literature does not provide evidence for an immediate requirement for surgery.
To assess the course of sciatica with discogenic paresis and to determine possible prognostic factors for recovery or improvement.
This open prospective multicenter study included patients with discogenic sciatica with paresis that had been developing for less than 1 month and was rated < or =3 on a 5-grade scale. Pain, the strength of 11 muscles, return to work, and analgesic intake were assessed at 1, 3, and 6 months. Recovery and improvement were defined by pain not exceeding 20 mm or < or =50% of the initial pain score and a score of either 5 (recovery) or 4 (improvement) for the weakest muscle at inclusion.
Sixty-seven patients were enrolled; 39 (58%) patients were treated surgically and 28 (42%) medically. Surgically treated patients differed from medically treated patients by a higher rate of extruded herniation, a higher number of paretic muscles (6.3 vs. 5; P = 0.051), and a longer course of sciatica (31.4 vs. 17.3 days; P = 0.034). At 6 months, 7 (10.4%) patients were lost to follow-up; 32 (53.3%) had improved, including 18 (30%) recovered, 33 (85%) back to work and having a professional activity, and 22 (39%) still taking analgesics. The only significant difference between recovered and not recovered patients was mean age at inclusion (43 vs. 51 years, P = 0.034). There were no significant differences between improved and not improved patients. Moreover, the outcome was not different in the two treatment groups: there were 17 (53%) improvements in surgically treated patients, including 8 (25%) recoveries, and 14 (56%) improvements in medically treated patients, including 8 (40%) recoveries.
This pilot study showed no difference between surgical or medical management for recovery or improvement in patients with discogenic paresis. These results need confirmation by a randomized study.
A systematic review was conducted within the Cochrane Collaboration Back Review Group.
To assess the effects of advice to stay active as a single treatment for patients with acute low back pain or sciatica.
Low back pain is a common reason for consulting a health care provider, and advice on daily activities constitutes an important part in the primary care management of low back pain.
All randomized studies available in systematic searches (electronic databases, contact with authors, reference lists) were included. Two reviewers independently selected trials for inclusion, assessed the validity of the included trials, and extracted data. Investigators were contacted to obtain missing information.
Four trials, with a total of 491 patients, were included. In all the trials, advice to stay active was compared with advice for bed rest. Two trials were assessed as having a low risk of bias, and two as having a moderate to high risk of bias. The results were heterogeneous. The results from one high-quality trial of patients with acute, simple low back pain found small differences in functional status (weighted mean difference on a 0 to 100 scale, 6.0; 95% CI, 1.5-10.5) and length of sick leave (weighted mean difference, 3.4 days; 95% CI, 1.6-5.2) in favor of staying active, as compared with advice to stay in bed 2 days. The other high-quality trial compared advice to stay active with advice to rest in bed 14 days for patients with sciatic syndrome, and found no differences between the groups. One of the high-quality trials also compared advice to stay active with advice to engage in exercises for patients with acute, simple low back pain, and found improvement in functional status and reduced sick leave in favor of advice to stay active.
The best available evidence suggests that advice to stay active alone has little beneficial effect for patients with acute, simple low back pain, and little or no effect for patients with sciatica. There is no evidence that advice to stay active is harmful for either acute low back pain or sciatica. Because there is no considerable difference between advice to stay active and advice for bed rest, and there are potential harmful effects of prolonged bed rest, it is reasonable to advise people with acute low back pain and sciatica to stay active. These conclusions are based on single trials.
Double-blinded randomized controlled trial.
To test the short-term efficacy of a single intravenous (IV) pulse of glucocorticoids on the symptoms of acute discogenic sciatica.
The use of glucocorticoids in the treatment of acute discogenic sciatica is controversial. A potential advantage of the IV pulse therapy is the ability to distribute high glucocorticoid concentrations to the area surrounding the prolapsed disc without the risks and inconveniences of an epidural injection.
Patients with acute sciatica (<6-week duration) of radiologically confirmed discogenic origin were randomized to receive either a single IV bolus of 500 mg of methylprednisolone or placebo. Clinical evaluation was performed in a double-blind manner on days 0, 1, 2, 3, 10, and 30. The primary outcome was reduction in sciatic leg pain during the first 3 days following the infusion; secondary outcomes were reduction in low back pain, global pain, functional disability, and signs of radicular irritation. The analysis was performed on an intent-to-treat basis using a longitudinal regression model for repeated measures.
A total of 65 patients were randomized, and 60 completed the treatment and the follow-up assessments. A single IV bolus of glucocorticoids provided significant improvement in sciatic leg pain (P = 0.04) within the first 3 days. However, the effect size was small, and the improvement did not persist. IV glucocorticoids had no effect on functional disability or clinical signs of radicular irritation.
Although an IV bolus of glucocorticoids provides a short-term improvement in leg pain in patients with acute discogenic sciatica, its effects are transient and have small magnitude.
The purpose of this study was to describe the long-term effect of image-guided percutaneous laser disk decompression (PLDD).
PLDD has been reported to be an alternative method to treat herniated lumbar disks. It has proved to be effective on a short-term basis. Although the procedure has been used for several years, few articles report on the long-term effect of the intervention.
Two hundred patients, who were treated with image-guided PLDD for herniated lumbar disks, were observed over a period of 4 +/- 1.3 years. Treatments were carried out under CT/fluoroscopy guidance with local anesthesia on an outpatient basis with an Nd:YAG laser of 1064 nm.
At follow-up, back pain was eliminated or reduced in 73% of the patients. Regarding sensorimotor impairment, PLDD did have a positive effect on 74% of the patients. In the majority of patients, the number of sick days and consumption of pain medication was reduced. In one patient, diskitis occurred as a complication of PLDD; 74% of the patients said they were satisfied with the outcome of the therapy; and 81.5% of the patients would have required another PLDD in cases of disk herniation.
From our clinical results, we conclude that image-guided PLDD is an effective and secure method to treat contained herniated lumbar disks. Advantages of the procedure include the minimally invasive approach on an out-patient basis and the low complication rate.
Sciatica resulting from disk herniation resolves in 70% of patients within 1 month, and in 90% of patients after 1 year, following nonsurgical treatment.¹ Although sciatica is usually caused by a mechanical abnormality, pathophysiologic considerations provide a sound rationale for local corticosteroid therapy; several lines of evidence suggest that biochemical factors might contribute to sciatica.
A randomized controlled trial.
To evaluate the long-term efficacy of infliximab, a monoclonal antibody against tumor necrosis factor alpha (TNF-alpha), in patients with acute/subacute sciatica secondary to herniated disc.
The results of experimental studies and our open-label trial support the use of infliximab in sciatica. Here we report the 1-year results of a randomized controlled trial (FIRST II, Finnish Infliximab Related STudy) evaluating the efficacy and safety of a single infusion of infliximab for sciatic pain.
Inclusion criteria were unilateral sciatic pain with a disc herniation concordant with the symptoms and signs of radicular pain. Patients had to be candidates for discectomy. Criteria for discectomy included (in addition to a symptomatic disc herniation on MRI) neural entrapment (straight leg raising [SLR] < or =60 degrees ) with either a short-term (2-4 weeks) severe or long-term (4-12 weeks) moderate leg pain. Forty patients were allocated to a single intravenous infusion of either infliximab 5 mg/kg or placebo. Differences in the clinical examination parameters (straight leg raise [SLR], muscle strength, sensory defects, tendon reflexes), patient-reported symptoms (leg and back pain using a visual analog scale [VAS], Oswestry disability, quality-of-life [RAND-36]), sick leaves, number of discectomies, and adverse effects between the two treatment groups over the 1-year follow-up were compared using Mann-Whitney U test or Student's t test, repeated-measures analysis, or Cox proportional hazards model. Logistic regression was used to assess the predictors of good response.
Sixty-seven percent of patients in the infliximab group reported no pain at 52 weeks compared with 63% in the control group (P = 0.72). Similar efficacy was observed between treatment groups for other outcomes. Eight patients in each group required surgery. Three nonserious adverse reactions were encountered in the infliximab group. The response (irrespective of the treatment) was significantly better with shorter symptom duration and less SLR restriction at baseline. Patients in the infliximab group appeared to especially benefit in cases of a L4-L5 (or L3-L4) herniation and if a Modic change was colocalized at the symptomatic level.
Although the long-term results of this randomized trial do not support the use of infliximab compared with placebo for lumbar radicular pain in patients with disc herniation-induced sciatica, further study in a subgroup of patients with L4-L5 or L3-L4 herniations, especially in the presence of Modic changes, appears to be warranted.
Disc prolapse accounts for five percent of low-back disorders but is one of the most common reasons for surgery.
The objective of this review was to assess the effects of surgical interventions for the treatment of lumbar disc prolapse.
We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Spine and abstracts of the main spine society meetings within the last five years. We also checked the reference lists of each retrieved articles and corresponded with experts. All data found up to 1 January 2007 are included.
Randomized trials (RCT) and quasi-randomized trials (QRCT) of the surgical management of lumbar disc prolapse.
Two review authors assessed trial quality and extracted data from published papers. Additional information was sought from the authors if necessary.
Forty RCTs and two QRCTs were identified, including 17 new trials since the first edition of this review in 1999. Many of the early trials were of some form of chemonucleolysis, whereas the majority of the later studies either compared different techniques of discectomy or the use of some form of membrane to reduce epidural scarring. Despite the critical importance of knowing whether surgery is beneficial for disc prolapse, only four trials have directly compared discectomy with conservative management and these give suggestive rather than conclusive results. However, other trials show that discectomy produces better clinical outcomes than chemonucleolysis and that in turn is better than placebo. Microdiscectomy gives broadly comparable results to standard discectomy. Recent trials of an inter-position gel covering the dura (five trials) and of fat (four trials) show that they can reduce scar formation, though there is limited evidence about the effect on clinical outcomes. There is insufficient evidence on other percutaneous discectomy techniques to draw firm conclusions. Three small RCTs of laser discectomy do not provide conclusive evidence on its efficacy, There are no published RCTs of coblation therapy or trans-foraminal endoscopic discectomy.
Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are still unclear. Microdiscectomy gives broadly comparable results to open discectomy. The evidence on other minimally invasive techniques remains unclear (with the exception of chemonucleolysis using chymopapain, which is no longer widely available).
An updated Cochrane Review.
To assess the effects of surgical interventions for the treatment of lumbar disc prolapse.
Disc prolapse accounts for 5% of low back disorders yet is one of the most common reasons for surgery. There is still little scientific evidence supporting some interventions.
Use of standard Cochrane review methods to analyze all randomized controlled trials published up to January 1, 2007.
Forty randomized controlled trials (RCTs) and 2 quasi-RCTs were identified. Many of the early trials were of some form of chemonucleolysis, whereas the majority of the later studies either compared different techniques of discectomy or the use of some form of membrane to reduce epidural scarring. Four trials directly compared discectomy with conservative management, and these give suggestive rather than conclusive results. However, other trials show that discectomy produces better clinical outcomes than chemonucleolysis, and that in turn is better than placebo. Microdiscectomy gives broadly comparable results to standard discectomy. Recent trials of an interposition gel covering the dura (5 trials) and of fat (4 trials) show that they can reduce scar formation, although there is limited evidence about the effect on clinical outcomes. There is insufficient evidence on other percutaneous discectomy techniques to draw firm conclusions. Three small RCTs of laser discectomy do not provide conclusive evidence on its efficacy. There are no published RCTs of coblation therapy or transforaminal endoscopic discectomy.
Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are still unclear. The evidence for other minimally invasive techniques remains unclear except for chemonucleolysis using chymopapain, which is no longer widely available.
Motifs d'ho-spitalisation en service de rhumatologie de 125 patients souffrant de scia-tique discale
- Berthelot Jm
- J Glemarec
- Y Laborie
- S Varin
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Le traitement des lomboradiculalgies Ancycl Med Chir Paris Appareil Locomoteur 1994
- Revel M B Loty
- Vallé
Revel M, Loty B, Vallé C. Le traitement des lomboradiculalgies. Ancycl Med Chir Paris Appareil Locomoteur 1994. 15-840-F-10.
Le traitement de la lombosciatique commune en milieu hospitalier: ré-tats d'une enquê d'opinion auprès des rhumatologues franç
- Rozenberg E S Legrand
- C Pascaretti
- F Blotman
- M Audran
- Valat
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Legrand E, Rozenberg S, Pascaretti C, Blotman F, Audran M, Valat JP. Le traitement de la lombosciatique commune en milieu hospitalier: ré-tats d'une enquê d'opinion auprès des rhumatologues franç. Rev Rhum 1998;65:530e6.
Peut-on pré le ré a court terme d'une hospitalisation pour sciatique dis-cale?
- Rodet D Berthelot Jm
- P Guillot
- Maugars Y Y Laborie
- Prost
Berthelot JM, Rodet D, Guillot P, Laborie Y, Maugars Y, Prost A. Peut-on pré le ré a court terme d'une hospitalisation pour sciatique dis-cale? Rev Rhum 1999;66:233e40.
Lombalgies: facteurs de risque exposants a ` la chronicité
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- P Goupille
- Vedere
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Les lomboradiculalgies des membres inférieurs
- COFER
Le traitement des lomboradiculalgies
- Revel
Le traitement de la lombosciatique commune en milieu hospitalier: résultats d'une enquête d'opinion auprès des rhumatologues français
- Legrand
Peut-on prédire le résultat a court terme d'une hospitalisation pour sciatique discale?
- Berthelot
Lombalgies: facteurs de risque exposants à la chronicité
- Valat
Motifs d'hospitalisation en service de rhumatologie de 125 patients souffrant de sciatique discale
- Berthelot