Computed tomography in low back pain and sciatica. A retrospective study of 132 patients in the Haute-Vienne district of France

AIMS

To evaluate physician compliance with the guidelines of the National Agency for Accreditation and Health Evaluation (ANAES) and the Consensus Conference on the use of medical imagery in low back pain and sciatica.

METHODS

We performed a retrospective study of 132 computed tomography scans (CTs) of the lumbar spine performed in one public and one private healthcare facility in the Haute-Vienne district, France. For each patent, the clinical findings, results of other investigations, prescriptions, and procedures reimbursed by the universal health insurance system were recorded.

RESULTS

Guidelines on imagery were followed in 2% of patients with chronic nonspecific low back pain. In 72% of patients, CT results had no influence on the subsequent clinical management. The guidelines were followed more often in patients with sciatica: 85% underwent CT more than 4 weeks after the initial painful episode. However, before CT was ordered, only 54% received appropriate initial treatment with analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), and/or muscle relaxants. Among these patients, 25% also received second-line medical therapy consisting of facet joint injection, conventional traction and, after the initial acute phase, physical therapy. In 39% of the sciatica patients, the imaging results had no effect on subsequent management. Among these patients, 12% underwent surgery for disk herniation.

CONCLUSIONS

Ten years after the consensus conference and despite the publication of the ANAES guidelines, there is still a wide gap between observed practice and recommendations for optimal management. The consequences of this extend beyond unnecessary expenses for the universal health insurance system to include important deleterious effects on the patients. In particular, prompt appropriate management may help to avoid progression to chronic low back pain and unnecessary imaging studies and surgical procedures, which often have devastating social and occupational consequences.

BOTOX and physical therapy in the treatment of piriformis syndrome

OBJECTIVE

This study evaluates the efficacy of botulinum toxin A injections used in conjunction with physical therapy for the treatment of piriformis syndrome.

DESIGN

This a double-blind, placebo controlled clinical trial using electrophysiologic criteria for patient selection and a visual analog scale to assess treatment efficacy in relieving pain.

RESULTS

As measured on the visual analog scale, patients injected with botulinum toxin A experienced more relief from pain than patients receiving lidocaine with steroid (P < 0.05) and more relief than patients receiving placebo (P = 0.001).

CONCLUSIONS

Injection with botulinum toxin A is an effective adjunct to physical therapy in the treatment of piriformis syndrome. H-reflex prolongation by flexion, adduction, and internal rotation (FAIR test) beyond 1.86 msec (3 SD) of the mean is a clinical indication of piriformis syndrome.

Cyclic sciatica related to an extrapelvic endometriosis of the sciatic nerve: new concepts in surgical therapy

Sciatic pain caused by endometriosis of the sciatic nerve is an uncommon clinical finding and seems to have been verified histologically in only a few cases. Patients complain of typical signs and symptoms of common sciatica that are cyclic in nature. Suggested compression of lumbar root or sciatic nerve or its plexus could be confirmed by electromyography, computed tomography, or magnetic resonance imaging, and by prompt response to hormonal suppression of ovarian function with regression of the radiologic findings. Patients often have required radical surgery with total hysterectomy and bilateral salpingo-oophorectomy. However, conservative surgery with excision of the endometriosis from the nerve can be successful in selected patients who wish to preserve reproductive function. We report a case of sciatic nerve involvement explored by magnetic resonance imaging, with endometriosis in contact with the nerve in the right sciatic trunk.

Can patient reactions to the first chiropractic treatment predict early favorable treatment outcome in persistent low back pain?

OBJECTIVE

To investigate whether 3 distinct patterns of reactions to chiropractic care predict early favorable treatment outcome in patients with persistent low back pain.

DESIGN AND SETTING

Multicenter, clinic-based prospective outcome study with standardized interview questionnaires conducted in private chiropractic practices in Sweden.

STUDY SUBJECTS

Previously compliant chiropractors were invited to participate in the study. A maximum of 20 consecutive patients (per chiropractor) who sought chiropractic care for low back pain with or without sciatica with a duration of more than 2 weeks at the time of consultation and for a minimum of 30 days total during the past year.

INTERVENTION

Chiropractic management as decided by the treating chiropractor. OUTCOME AND PREDICTOR VARIABLES: Improvement was defined at the 4th visit as self-reported "definitely improved" (the best of 5 choices). The hypothesized most favorable prognostic group had immediate improvement reported on the 1st visit, reduced pain intensity reported on the 2nd visit, reduced disability reported on the 2nd visit, and a common reaction or no reaction reported on the 2nd visit. The hypothesized least favorable prognostic group had no immediate improvement on the 1st visit, no reduction of pain intensity on the 2nd visit, no reduced disability on the 2nd visit, and no reaction or an uncommon reaction reported on the 2nd visit. The hypothesized intermediate prognostic group included all patients who did not fit into the hypothesized most favorable or least favorable groups. COVARIABLES: Age, sex, pain intensity during past 24 hours, description of disability, duration and pattern of pain during present attack, duration and pattern of pain during past 12 months. ANALYSIS OF DATA: The 3 predictor-groups were cross-tabulated against the outcome variable and the other covariates.

RESULTS

Of the 115 patients in the most favorable prognostic group, 84% (95% confidence interval, 77-91) reported to be "definitely improved" by the 4th visit versus 63% (59-67) of the 384 patients in the intermediate prognostic group, and 30% (22-38) of the 116 patients in the least favorable prognostic group. No major interactions from the covariates could explain these results.

CONCLUSION

Among chiropractic patients with persistent low back pain, it is possible to predict which patients will report definite improvement early in the course of treatment.

The cochrane review of advice to stay active as a single treatment for low back pain and sciatica

STUDY DESIGN

A systematic review was conducted within the Cochrane Collaboration Back Review Group.

OBJECTIVES

To assess the effects of advice to stay active as a single treatment for patients with acute low back pain or sciatica.

SUMMARY OF BACKGROUND DATA

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Lumbosacral radiculopathies: conservative approaches to management

The prevalence of sciatica in Western society and its economic and functional impact make it an important problem to understand for treatment. Such understanding will impact greatly both medical management and decisions regarding activity, which could affect the perceived disability and financial dependence of a patient. This knowledge could be used to direct primary prevention, patient education, and future research efforts in back pain. The article also discusses that such strategies could improve health, decrease disability, and rein in costs.

Cauda equina syndrome following traction for acute sciatica

A case report of a patient who developed cauda equina syndrome following pelvic traction for acute sciatica is presented. A good outcome was obtained with prompt surgical decompression. This case illustrates the potential dangers of traction, which is frequently employed in the management of acute back pain.

Osteophyte at the sacroiliac joint as a cause of sciatica: a report of four cases

Four cases of sciatica due to osteophytes impinging on the sciatic nerve at the sacroiliac joint are reported. Of these 4 cases, 2 were treated conservatively and the other 2 required surgical excision of the osteophyte. The report highlights the importance of keeping this uncommon etiology in the differential diagnosis of sciatica.

MRI-guided periradicular nerve root infiltration therapy in low-field (0.23-T) MRI system using optical instrument tracking

The purpose of this study was to evaluate the feasibility of the MRI-guided periradicular nerve root infiltration therapy. Sixty-seven nerve root infiltrations under MRI guidance were done for 61 patients suffering from lumbosacral radicular pain. Informed consent was acquired from all patients. A 0.23-T open-MRI scanner with interventional tools (Outlook Proview, Philips Medical Systems, MR Technologies, Finland) was used. A surface coil was used in all cases. Nerve root infiltration was performed with MRI-compatible 20-G needle (Chiba type MReye, Cook, Bloomington, Ind.; or Manan type, MD Tech, Florida). The evaluation of clinical outcome was achieved with 6 months of clinical follow-up and questionnaire. The effect of nerve root infiltration to the radicular pain was graded: 1=good to excellent, i.e., no pain or not disturbing pain allowing normal physical activity at 3 months from the procedure; 2=temporary, i.e., temporary relief of pain; 3=no relief of pain; and 4=worsening of pain. As an adjunct to MRI-guided positioning of the needle the correct needle localization by the nerve root was confirmed with saline injection to nerve root channel and single-shot fast spin echo (SSFSE) imaging. The MRI guidance allowed adequate needle positioning in all but 1 case (98.5%). This failure was caused by degeneration-induced changes in anatomy. Of patients, 51.5% had good to excellent effect with regard to radicular pain from the procedure, 22.7% had temporary relief, 21.2% had no effect, and in 4.5% the pain worsened. Our results show that MRI guidance is accurate and safe in performing nerve root infiltration at lumbosacral area. The results of radicular pain relief from nerve root infiltration are comparable to CT or fluoroscopy studies on the subject.

Piriformis syndrome: diagnosis, treatment, and outcome--a 10-year study

OBJECTIVES

To validate an operational definition of piriformis syndrome based on prolongation of the H-reflex with hip flexion, adduction, and internal rotation (FAIR) and to assess efficacy of conservative therapy and surgery to relieve symptoms and reduce disability.

DESIGN

Before-after trial of cohorts identified by operational definition.

SETTING

Outpatient departments of 2 hospitals and 4 physicians' offices. Surgery performed at 3 hospitals.

PATIENTS

Consecutive sample of 918 patients (1014 legs) with follow-up on 733.

INTERVENTION

Patients with significant (3 standard deviations [SDs]) FAIR tests received injection, physical therapy, and serially reported pain and disability assessments. Forty-three patients (6.47%) had surgery.

MAIN OUTCOME MEASURES

Likert pain scale. Subjective estimates of disablement in activities of daily living and instrumental activities of daily living.

RESULTS

At 3 SDs, the FAIR test had sensitivity and specificity of.881 and.832, respectively. Seventy-nine percent (514/655) of FAIR test positive (FTP) patients improved 50% or more from injection and physical therapy at a mean follow-up of 10.2 months. Average improvement was 71.1%. Of 385 FTP patients with disability data, mean disability fell from 35.37% prestudy (SD =.2275) to 12.96% poststudy (SD =.1752), a 62.8% improvement. Twenty-eight surgical FTP patients (68.8%) showed 50% or greater improvement; mean improvement was 68% at a mean follow-up of 16 months. Surgery reduced the mean FAIR test to 1.35 +/- 2.17 months postoperatively. FTP patients generally improved 10% to 15% more than others after conservative treatment.

CONCLUSIONS

The FAIR test correlates well with a working definition of piriformis syndrome and is a better predictor of successful physical therapy and surgery than the working definition. The FAIR test, coupled with injection and physical therapy and/or surgery, appears to be effective means to diagnose and treat piriformis syndrome.

Persistent low back pain and sciatica in the United States: treatment outcomes

Patients with persistent low back pain (LBP) appear to be different in several important ways from patients who have traditionally been classified as patients with acute or chronic LBP, and data on the effectiveness of the treatments prescribed for them are lacking. The aim of the current study was to evaluate the short- and long-term effectiveness of the treatments currently prescribed for these patients. The data reported in this article were gathered as part of a multicenter, prospective, cross-sectional study of patients who were treated for persistent LBP by neurologic and orthopedic surgeons who are recognized specialists in spinal disorders. At enrollment, patients completed a baseline evaluation, and their physicians recorded relevant clinical and treatment data on standardized study forms. At 3, 6, 12, and 24 months after treatment, patients completed follow-up evaluations. Patients were divided into five treatment groups, and effectiveness was evaluated separately for each group using five patient-reported measures of outcome: pain severity, functional disability, psychologic distress, physical symptoms, and health care use. The data revealed that at the 2-year follow-up, the typical patient of the no-treatment group had improved slightly in terms of pain severity and health care use, but had experienced little or no improvement in functional disability, physical symptoms, and psychologic distress. The average patient in the conservative care group reported small improvements in pain severity, functional disability, physical symptoms, and health care use, with no change in psychologic distress. These small improvements occurred within the first 3 months after enrollment, with essentially no change thereafter. The average patient in the immediate surgical care group showed substantial improvement on all of the outcome measures. The observed improvements were evident shortly after treatment and were maintained for the duration of the study. Patients in the delayed surgical care group had outcomes that were less dramatic than those observed in the immediate surgery care group, but greater than those observed in the conservative care group. The patients who were treated surgically by physicians outside the study, outside surgical care group, did not improve over time. Patients with persistent LBP who received no treatment showed no spontaneous recovery. Conservative care treatments prescribed by surgeons who specialize in spinal disorders, did not appear to be any more effective than no treatment. The outcome of surgery for persistent LBP varied from dramatic for one subgroup of surgical patients, to poor for another subgroup of patients. Patients who were selected immediately for surgical treatment improved substantially. Those treated surgically later by study physicians or by physicians not associated with the study fared less well.

Sacral magnetic stimulation for pain relief from pudendal neuralgia and sciatica

INTRODUCTION

Magnetic stimulation of the sacral nerve roots is used for neurologic examination. However, no one has reported therapeutic efficacy of pain relief from pudendal neuralgia with sacral magnetic stimulation.

METHODS

Five patients with pudendal neuralgia or sciatica received 30 to 50 pulsed magnetic stimuli of the sacral nerve roots. The median age of the patients was 59 (range, 28-69) years; there were 3 females.

RESULTS

Sacral magnetic stimulation immediately eliminated the pain. The pain relief lasted between 30 minutes and 56 days (median, 24 hours). Adverse effects were not observed.

CONCLUSIONS

This pilot study indicates that magnetic stimulation of the sacral nerve roots may be a promising therapeutic modality for pain relief from pudendal neuralgia and sciatica. Further studies should be performed to determine the appropriate intensity and frequency, as well as the utility of a second course, of magnetic stimulation treatment.

[Continual epidural therapy in lumbosciatic syndrome. Personal experience]

BACKGROUND

The purpose of this retrospective study was to evaluate the effects of associating several currently used drugs: local anesthetics, corticosteroids, morphine hydrochloride and clonidine administered using continual epidural in lumbosciatic back pain. The association of an opiate and a solution of local anesthetic through infusion increases the analgesic effect and allows smaller quantities of both drugs to be used. The addition of another drug, like clonidine, may allow the dose of the single drugs to be reduced even further, thus resulting in fewer dose-dependent side effects. We know that at least two of the opiate receptor systems and at least three non-opiates modulate the painful sensory afferences. The cortisones can act as both antiphlogistics and antiedemigens, as well as inhibition prostaglandin.

METHODS

All the patients in this study were hospitalised after varying periods of home therapy or in other wards. The case histories of 462 patients were studied on admission using routine X-rays and laboratory tests, and also based on a chart divided into parts: the first showed the marks for EO of a patient with lumbosciatica, and the second contained pain-related data. This was measured both directly, using the Scott-Huskisson visual parallel and a language card, and indirectly (possible activities, drug intake, etc.). The scale of the analog used defines slight pain with values of less than 44 mm, moderate pain with values between 45-69 mm, strong pain with values between 70-88 mm, and very strong pain above 88 mm.

RESULTS

The following results were obtained from this study: successes 87.9%, partial successes 1.7%, failures 10.3%. Of the 48 failures, 31 were operated within a few days, whereas the remaining 17 cases were not operated because the patients declared that they were satisfied with the improvement obtained or gave other reasons. The analgesic effect was frequently observed. The improvement usually increased after the second block so that some patients did not require a third administration.

CONCLUSIONS

The results confirm that continual epidural therapy is the most successful and also the most rapid treatment available for pain of lumbar origin. At present we share Finneson's opinion that the same general indications are still valid: 1) discopathy with negative NMR; 2) discopathy with medical contraindications to surgery; 3) discopathy of lumbar and/or radicular origin with alterations to multiple NMR and no reliable signs of a specific root; 4) for symptomatic purposes while waiting for diagnosis and surgery.

Advice to stay active as a single treatment for low back pain and sciatica

BACKGROUND

Low back pain is one of the most common conditions managed in primary care. Restricted activity, rest, and symptomatic analgesics are the most commonly prescribed treatment for low back pain and sciatica.

OBJECTIVES

To assess the effects of advice to stay active as single treatment for patients with low back pain.

SEARCH STRATEGY

Computerised searches in MEDLINE, EMBASE, Sport, The Cochrane Controlled Trials Register, Musculoskeletal Group's Trials Register and Scisearch, and scanning of reference lists from relevant articles were undertaken. Relevant studies were also traced by contacting authors. Date of the most recent searches: December 1998.

SELECTION CRITERIA

We included all randomised trials or quasi-randomised trials where the study population consisted of adult patients with low back pain or sciatica, in which one comparison group was advised to stay active. The main outcomes of interest were pain, functional status, recovery and return to work.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion, assessed the validity of included trials and extracted data. Investigators were contacted to collect missing data or for clarification when needed.

MAIN RESULTS

Four trials, with a total of 491 patients, were included. Advice to stay active was compared to advice to rest in bed in all trials. Two trials were assessed to have low risk of bias and two to have moderate to high risk of bias. The results were heterogeneous. Results from one high quality trial of patients with acute simple LBP found small differences in functional status [Weighted Mean Difference (on a 0-100 scale) 6.0 (95% CI: 1.5, 10.5)] and length of sick leave [WMD 3.4 days (95% CI: 1.6, 5.2)] in favour of staying active compared to advice to stay in bed for two days. The other high quality trial compared advice to stay active with advice to rest in bed for 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 exercises for patients with acute simple LBP, and found improvement in functional status and reduction in sick leave in favour of advice to stay active.

REVIEWER'S CONCLUSIONS

The best available evidence suggests that advice to stay active alone has small beneficial effects 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. If there is no major difference between advice to stay active and advice to rest in bed, and there is potential harmful effects of prolonged bed rest, then it is reasonable to advise people with acute low back pain and sciatica to stay active. These conclusions are based on single trials.

Selective nerve root blocks for the treatment of sciatica: evaluation of injection site and effectiveness--a study with patients and cadavers

PURPOSE

To relate different types of radiographic contrast material distributions to anatomic compartments by using cadaveric specimens and to relate the injection site to treatment-induced discomfort and therapeutic effect.

MATERIALS AND METHODS

The contrast material distributions of selective nerve root blocks (SNRBs) in 36 patients (13 women, 23 men; mean age, 52 years; age range, 22-88 years) were graded by two radiologists in conference as type 1 (tubular appearance), type 2 (nerve root visible as filling defect), or type 3 (nerve root not visible). These patterns were correlated with pain reduction after 15 minutes and 2 weeks (with a visual analogue scale of 100-mm length). In addition, 30 nerve roots were injected with iodine-containing contrast material and blue dye in three cadaveric specimens. Radiographs were compared with anatomic sections.

RESULTS

After 15 minutes and 2 weeks, 75% and 86% of the patients, respectively, reported pain relief. Mean pain relief length after 15 minutes for type 1 distribution was 60 mm; for type 2, 44 mm; and for type 3, 22 mm; and after 2 weeks, it was 34 mm for type 1, 31 mm for type 2, and 57 mm for type 3. There was no correlation between early and late response. Pain during intervention was less pronounced in type 2 injection, compared with type 1 (P = .002). On the basis of anatomic sections, type 1 injection was intraepineural; type 2, extraepineural; and type 3, paraneural.

CONCLUSION

Therapeutic SNRB is effective in sciatica, but early response does not predict the effect after 2 weeks. Type 1 injections are more painful than type 2 injections.

The centralization phenomenon in chiropractic spinal manipulation of discogenic low back pain and sciatica

OBJECTIVE

To describe 3 cases of discogenic low back pain and leg pain in which the centralization phenomenon was used in determining chiropractic treatment and prognosis.

CLINICAL FEATURES

Three men with low back pain and sciatica, positive straight leg raise, mild neurologic deficits, and evidence of discogenic disease requested chiropractic treatment. Two of the patients exhibited centralization of pain on provocation testing; the third did not.

INTERVENTION AND OUTCOME

All patients were treated with chiropractic side-posture manipulation, ancillary therapies, and pain medications. The 2 subjects whose pain centralized had excellent outcomes to treatment. The one whose pain did not centralize had a poor outcome and eventually required surgery.

CONCLUSION

Assessment of the centralization phenomenon provided valuable diagnostic and prognostic information regarding chiropractic side-posture manipulation in this case series.

A descriptive study of medical and chiropractic patients with chronic low back pain and sciatica: management by physicians (practice activities) and patients (self-management)

BACKGROUND

A practice-based study of ambulatory patients with low back pain noted a long-term outcome advantage for self-referred chiropractic (DC) patients over medical (MD) patients within a subgroup of patients with chronic low back pain and radiating pain below the knee. The frequency of self-care education by physicians in both provider cohorts coupled with current thinking on management of chronic low back pain led to an exploration and description of physicians' noncore practice activities and patients' self-management attitudes and behaviors.

METHODS

A longitudinal, practice-based, observational study was undertaken in 14 general practice and 51 chiropractic community-based clinics. We enrolled 2945 consecutive patients with ambulatory low back pain of mechanical origin; of these, 268 comprised the subgroup of patients with chronic low back pain and radiating pain below the knee. The patients' low back status was followed for 1 year. Data on physicians' practice activities were obtained from doctor questionnaires completed at each patient visit and from chart abstraction. Patient data obtained from self-administered questionnaires at enrollment included sociodemographics, complaint characteristics, health status, and health encounter preferences. Questionnaires mailed at 2 weeks, 1 month, 3 months, 6 months, and 12 months collected data on low back complaint status and satisfaction with treatment. At 1 to 3 years follow-up, mailed questionnaires collected data on patients' self-management attitudes and behaviors.

RESULTS

Physicians' core practice activities were as expected. Exercise plans and self-care education (>55%) were conspicuous in the frequency of their use in the DC cohort. MD patients appeared to rely more on family and friends for support during periods of back trouble. DC patients were characterized by greater self-efficacy motivation (P = .000). Both groups showed evidence of self-care activities during and between bouts of back pain, although MD patients were far more likely to choose bed rest (P = .007).

CONCLUSIONS

The chiropractic encounter may have enhanced patients' self-efficacy motivation, leading to better coping abilities and better pain and disability outcomes. Understanding, respecting, and capitalizing on the role and influence of psychosocial factors can help all physicians become more effective healers and counselors for their patients with back pain.

Stiffness and neuromuscular reflex response of the human spine to posteroanterior manipulative thrusts in patients with low back pain

BACKGROUND

Studies investigating posteroanterior (PA) forces in spinal stiffness assessment have shown relationships to spinal level, body type, and lumbar extensor muscle activity. Such measures may be important determinants in discriminating between patients who are asymptomatic and those who have low back pain. However, little objective evidence is available concerning variations in PA stiffness and their clinical significance. Moreover, although several studies have assessed only load input in relation to stiffness, a more complete assessment based on dynamic stiffness measurements (force/velocity) and concomitant neuromuscular response may offer more information concerning mechanical properties of the low back.

OBJECTIVE

To determine the stiffness and neuromuscular characteristics of the symptomatic low back.

STUDY DESIGN

This study is a prospective clinical study investigating the in vivo mechanical and muscular behavior of human lumbar spinal segments to high loading rate PA manipulative thrusts in research subjects with low back pain (LBP).

METHODS

Twelve men and 10 women, aged 15 to 73 years (mean age of 42.8 +/- 17.5 years) underwent physical examination and completed outcome assessment instruments, including Visual Analog Scale, Oswestry Low Back Disability Index, and SF-36 health status questionnaires. Clinical categorization was made on the basis of symptom frequency and LBP history. A hand-held spinal manipulation device, equipped with a preload control frame and impedance head, was used to deliver high-rate (<0.1 millisecond) PA manipulative thrusts (190 N) to several common spinal landmarks, including the ilium, sacral base, and L5, L4, L2, T12, and T8 spinous and transverse processes. Surface, linear-enveloped, electromyographic (sEMG) recordings were obtained from electrodes (8 leads) located over the L3 and L5 paraspinal musculature to monitor the bilateral neuromuscular activity of the erector spinae group during the PA thrusts. Maximal-effort isometric trunk extensions were performed by the research subjects before and immediately after the testing protocol to normalize sEMG data. The accelerance or stiffness index (peak acceleration/peak force, kg-1) and composite sEMG neuromuscular reflex response were calculated for each of the thrusts.

RESULTS

Posteroanterior stiffness obtained at the sacroiliac joints, transverse processes, or spinous processes was not different for subjects grouped according to LBP chronicity. However, in those with frequent or constant LBP symptoms, there was a significantly increased spinous process (SP) stiffness index (7.0 kg-1) (P <.05) in comparison with SP stiffness index (6.5 kg-1) of subjects with only occasional or no LBP symptoms. Subjects with frequent or constant LBP symptoms also reported significantly greater scores on the visual analog scale (P =.001), Oswestry (P =.001), and perceived health status (P =.03) assessments. The average SP stiffness index was 6.6% greater (P <.05) and 19.1% greater (P <.001) than the average sacroiliac stiffness index and average transverse process stiffness index, respectively.

CONCLUSIONS

This study is the first to assess erector spinae neuromuscular reflex responses simultaneously during spinal stiffness examination. This study demonstrated increased spinal stiffness index and positive neuromuscular reflex responses in subjects with frequent or constant LBP as compared with those reporting intermittent or no LBP.

[Low back pain and sciatica]

In order to see the patients with low back pain and/or sciatica, it is most important to consider the pathophysiology of symptoms. We should know that the image findings such as X-ray and MRI do not always show the cause of symptom. Because degenerative changes in lumbar spine are common findings in asymptomatic group compared to symptomatic patients with low back pain and sciatica. According to pathophysiology (nerve root syndrome, cauda equina syndrome, facet syndrome, discogenic pain syndrome and intermittent claudication for low back pain), the treatment for low back pain and sciatica were described.

The "piriformis syndrome"--myth or reality?

This article has been retracted. See the retraction notice for details. The PDF is retained for transparency.

Surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: five-year outcomes from the Maine Lumbar Spine Study

STUDY DESIGN

A prospective cohort study.

OBJECTIVE

To assess 5-year outcomes for patients with sciatica caused by a lumbar disc herniation treated surgically or nonsurgically.

SUMMARY OF BACKGROUND DATA

There is limited knowledge about long-term treatment outcomes of sciatica caused by a lumbar disc herniation, particularly the relative benefits of surgical and conservative therapy in contemporary clinical practice.

METHODS

Eligible, consenting patients recruited from the practices of orthopedic surgeons, neurosurgeons, and occupational medicine physicians throughout Maine had baseline interviews with mailed follow-up questionnaires at 3, 6, and 12 months and annually thereafter. Clinical data were obtained at baseline from a physician questionnaire. Outcomes included patient-reported symptoms of leg and back pain, functional status, satisfaction, and employment and compensation status.

RESULTS

Of 507 patients initially enrolled, 5-year outcomes were available for 402 (79.3%) patients: 220 (80%) treated surgically and 182 (78.4%) treated nonsurgically. Surgically treated patients had worse baseline symptoms and functional status than those initially treated nonsurgically. By 5 years 19% of surgical patients had undergone at least one additional lumbar spine operation, and 16% of nonsurgical patients had opted for at least one lumbar spine operation. Overall, patients treated initially with surgery reported better outcomes. At the 5-year follow-up, 70% of patients initially treated surgically reported improvement in their predominant symptom (back or leg pain) versus 56% of those initially treated nonsurgically (P < 0.001). Similarly, a larger proportion of surgical patients reported satisfaction with their current status (63% vs. 46%, P < 0.001). These differences persisted after adjustment for other determinants of outcome. The relative advantage of surgery was greatest early in follow-up and narrowed over 5 years. There was no difference in the proportion of patients receiving disability compensation at the 5-year follow-up. The least symptomatic patients at baseline did well regardless of initial treatment, although function improved more in the surgical group.

CONCLUSIONS

For patients with moderate or severe sciatica, surgical treatment was associated with greater improvement than nonsurgical treatment at 5 years. However, patients treated surgically were as likely to be receiving disability compensation, and the relative benefit of surgery decreased over time.

Evaluating and managing acute low back pain in the primary care setting

Acute low back pain is a common reason for patient calls or visits to a primary care clinician. Despite a large differential diagnosis, the precise etiology is rarely identified, although musculoligamentous processes are usually suspected. For most patients, back symptoms are nonspecific, meaning that there is no evidence for radicular symptoms or underlying systemic disease. Because episodes of acute, nonspecific low back pain are usually self-limited, many patients treat themselves without contacting their primary care clinician. When patients do call or schedule a visit, evaluation and management by primary care clinicians is appropriate. The history and physical examination usually provide clues to the rare but potentially serious causes of low back pain, as well as to identify patients at risk for prolonged recovery. Diagnostic testing, including plain x-rays, is often unnecessary during the initial evaluation. For patients with acute, nonspecific low back pain, the primary emphasis of treatment should be conservative care, time, reassurance, and education. Current recommendations focus on activity as tolerated (though not active exercise while pain is severe) and minimal if any bed rest. Referral for physical treatments is most appropriate for patients whose symptoms are not improving over 2 to 4 weeks. Specialty referral should be considered for patients with a progressive neurologic deficit, failure of conservative therapy, or an uncertain or serious diagnosis. The prognosis for most patients is good, although recurrence is common. Thus, educating patients about the natural history of acute low back pain and how to prevent future episodes can help ensure reasonable expectations.

Primary pelvic hydatid cyst: an unusual cause of sciatica and foot drop

STUDY DESIGN

A case report of primary pelvic hydatid cyst causing sciatica and foot drop.

OBJECTIVE

To document the occurrence of primary pelvic hydatid cyst as one of the hidden causes of lower limb weakness and foot drop, and to recommend inclusion of the pelvic cavity when assessing sciatica and foot drop.

SUMMARY OF BACKGROUND DATA

It is common to see foot drop caused by peripheral lesions around the knee or disc herniation in the lumbar spine, but if these sites were excluded, the pelvic cavity must be examined for hidden disease that may explain the cause of foot drop and sciatica.

METHODS

The authors involved in the care and management of this patient were interviewed and all medical records, radiologic investigations, and related literature were reviewed.

RESULTS

After exclusion of spinal and peripheral causes of foot drop, computed tomography of the pelvis showed a well-localized cystic swelling in the right side of the pelvis over the lumbosacral plexus roots. Surgical excision of the cyst resulted in partial recovery of the foot drop at 3 years of follow-up.

CONCLUSION

Primary pelvic hydatid cyst rarely causes pressure on the lumbosacral plexus. This was a case of hydatid cyst in the pelvis causing sciatica and foot drop, and it indicates the pelvis as a hidden source of sciatica and foot drop. After surgical excision followed by 4 months' mebendazole therapy, there was no evidence of recurrence on long-term follow-up.

Conservative treatment of sciatica: a systematic review

Most patients with sciatica (often caused by disc herniations) are managed conservatively at first. The natural course seems to be favorable. The additional value of many conservative therapies remains controversial. Because a systematic review of the conservative treatment of sciatica is lacking, such a review was carried out. After a standardized literature search and selection procedure, methodology and outcome of randomized controlled trials (RCTs) were assessed by three observers. If possible, trial results were statistically pooled (= metaanalysis). The 19 RCTs that were selected showed greatly varying methodologic quality. Pooled odds ratios were calculated for several treatment types. Neither traction, exercise therapy, nor drug therapy was unequivocally effective. Epidural steroids may be beneficial for subgroups of nerve root compression. The literature suggests possible effectiveness of epidural steroids for sciatica. The authors recommend trials to investigate this treatment option further, especially with regard to patient subgroups (e.g., acute sciatica). The effects of clinical heterogeneity and methodology on review results are illustrated.

Neurotrophin-3 antisense oligonucleotide attenuates nerve injury-induced Abeta-fibre sprouting

It is proposed that following peripheral nerve injury abnormal sprouting of Abeta-fibre primary afferent neurons in the spinal cord contributes to the allodynia that often occurs with such injury. Allodynia is characterized as pain due to a stimulus which is normally non-noxious. Our recent in vivo experiments show that intrathecal administration of neurotrophin-3 (NT-3), in normal animals, induces allodynia and sprouting of Abeta-fibres. In this study, we examine whether intrathecal administration of NT-3 antisense oligonucleotides (50 microM), via an osmotic pump for 14 days, attenuates nerve injury-induced sprouting and allodynia. The oligonucleotides used in this study were phosphorothioate modified and control experiments, using an ELISA, confirm that intrathecal administration of the antisense induces a significant decrease in NT-3 levels in the spinal cord. All surgery was conducted on anaesthetized Wistar rats (sodium pentobarbitone, i.p. 50 mg/kg). Consistent with previous studies, transganglionic labelling of Abeta-fibres with choleragenoid-horseradish peroxidase (C-HRP) shows that complete transection of the sciatic nerve induces an expansion of C-HRP label into lamina II of the spinal dorsal horn. Using image analysis, we find that intrathecal administration of NT-3 antisense attenuates the density of C-HRP labelling in lamina II in nerve injured animals. A NT-3 sense oligonucleotide (50 microM) has no effect. To test the effect of NT-3 antisense on allodynia, the nociceptive flexion reflex is examined, using an Ugo Basile Analgesymeter, in animals with partial sciatic nerve ligation. Intrathecal administration of 50 microM NT-3 antisense significantly attenuates nerve injury-induced allodynia, whereas the sense oligonucleotide has no effect. These results provide further evidence that endogenous NT-3 contributes to both nerve injury-induced Abeta-fibre sprouting and allodynia and demonstrates the potential of neurotrophin-3 antisense oligonucleotides as therapeutic agents for neuropathic pain.

Nonoperative treatments for sciatica: a pilot study for a randomized clinical trial

OBJECTIVES

To assess the feasibility of patient recruitment, the ability of patients and clinicians to comply with study protocols, and the use of data collection instruments to collect cost-effectiveness data, and to obtain variability estimates for sample-size calculations for a full-scale trial.

STUDY DESIGN

Prospective, observer-blinded, pilot randomized clinical trial.

SETTING

Primary contact chiropractic and medical clinics.

PATIENTS

Ages 20 to 65 years, with low back-related radiating leg pain (sciatica).

OUTCOME MEASURES

Self-report questionnaires were administered at baseline and 3 and 12 weeks after randomization. The measures included leg and back pain severity, frequency and bothersomeness of symptoms, leg/back disability, medication use, global improvement, satisfaction, and health care utilization.

INTERVENTIONS

Medical care, chiropractic care, and epidural steroid injections.

RESULTS

A total of 706 persons were screened by phone to determine initial eligibility. Of these, over 90% of those persons contacted did not meet the entrance criteria. The most common reason for disqualification was that the duration of the complaint was longer than 3 months. Twenty patients were randomized into the study. All 3 groups showed substantial improvements in the main patient-rated outcomes at the end of the 12-week intervention phase. For leg pain, back pain, frequency and bothersomeness of leg symptoms, and Roland-Morris disability score, the percent improvement varied from 50% to 84%, and the corresponding effect sizes ranged from 0.8 to 2.2. Bothersomeness of leg symptoms was the most responsive outcome associated with the largest magnitude of effect size. All within-group changes from baseline were statistically significant (P <.01). No between-group comparisons were planned or performed because of the insufficient sample size and high risk of committing type I and type II errors.

CONCLUSIONS

Pilot studies such as these are important for the determination of the feasibility of conducting costly, larger scale trials. Recruitment for a full-scale study of sciatica of 2 to 12 weeks duration is not feasible, given the methods used in this pilot study. Our results do indicate, however, that there are substantial numbers of patients with sciatica more chronic in nature who would be interested in participating in a similar study. In addition, collaboration with a local health maintenance organization would likely facilitate clinician referrals and optimize the recruitment process. Patient and provider compliance was high in the pilot study, which indicates that most study protocols are feasible. Additionally, we were able to collect complete outcomes data, including those regarding health care use. A suggested modification by investigators and outside consultants has resulted in the replacement of the medication group with a minimal intervention control group (ie, self-care advice). As a result, a second pilot study of patients with sciatica of more than 4 weeks duration has been planned before a full-scale trial is attempted.

Nerve root infiltration of the first sacral root with MRI guidance

The purpose of this clinical trial was to describe the methodology and evaluate the accuracy of optical tracking-based magnetic resonance (MR)-guided infiltration of the first sacral (S1) root. Thirty-five infiltrations were performed on 34 patients with a 0. 23-T open C-arm magnet installed in a fully equipped operation room with large-screen (36 inches) display and optical navigator utilizing infrared passive tracking. T1 and T2 fast spin-echo (FSE) images were used for localizing the target and fast field echo for monitoring the procedure. Saline as contrast agent in single-shot (SS)FSE images gave sufficient contrast-to-noise ratio. Twenty-four patients had unoperated L5/S1 disc herniation, and 10 had S1 root irritation after failed back surgery. Needle placement was successful in 97% of the cases, and no complications occurred. Outcome was evaluated 1-6 months (mean 2.2 months) after the procedure and was comparable to that of other studies using fluoroscopy or computed tomography guidance. MR-guided placement of the needle is an accurate technique for first sacral root infiltration.

The efficacy of spinal cord stimulation for chronic pain

A prospective study was undertaken to evaluate the efficacy of spinal cord stimulation (SCS) in the management of chronic pain syndrome. The study included all patients who underwent this procedure at the Royal Melbourne Hospital and the Melbourne Private Hospital over a period of two years. A total of 29 patients were managed by the end of June 1996. These patients were carefully screened by a neurosurgeon (JVR) and a psychiatrist. Of these, 26 patients had a follow up evaluation at the end of August 1996. From the group of 29 patients, four patients failed to obtain any relief during the trial phase of the procedure and thus did not have the stimulator implanted permanently. From the 25 patients who proceeded to have the stimulator implanted, 11 patients had a variable beneficial response, three patients found it to be of marginal benefit, six had no benefit, three patients initially had a good response but subsequently gained no benefit whilst two patients were uncertain of its benefit. It thus appears that SCS was of benefit in 50% of our carefully selected patients with chronic pain syndromes.

Single-blind randomised controlled trial of chemonucleolysis and manipulation in the treatment of symptomatic lumbar disc herniation

This single-blind randomised clinical trial compared osteopathic manipulative treatment with chemonucleolysis (used as a control of known efficacy) for symptomatic lumbar disc herniation. Forty patients with sciatica due to this diagnosis (confirmed by imaging) were treated either by chemonucleolysis or manipulation. Outcomes (leg pain, back pain and self-reported disability) were measured at 2 weeks, 6 weeks and 12 months. The mean values for all outcomes improved in both groups. By 12 months, there was no statistically significant difference in outcome between the treatments, but manipulation produced a statistically significant greater improvement for back pain and disability in the first few weeks. A similar number from both groups required additional orthopaedic intervention; there were no serious complications. Crude cost analysis suggested an overall financial advantage from manipulation. Because osteopathic manipulation produced a 12-month outcome that was equivalent to chemonucleolysis, it can be considered as an option for the treatment of symptomatic lumbar disc herniation, at least in the absence of clear indications for surgery. Further study into the value of manipulation at a more acute stage is warranted.

Bed rest for acute low back pain and sciatica

BACKGROUND

Low back pain is a common reason for consulting a general practitioner, and advice on daily activities constitutes an important part in the primary care management of low back pain.

OBJECTIVES

To assess the effects of bed rest for patients with acute low back pain or sciatica.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Group trial register, Cochrane Controlled Trials Register, MEDLINE, Embase, Sport, Scisearch, and reference lists of relevant articles. We also contacted authors of relevant articles. Date of the most recent searches: December 1998.

SELECTION CRITERIA

We included all randomised studies or quasi randomised studies where at least one comparison group of adult patients with acute low back pain with or without radiation of pain below the knee was advised to rest in bed for at least two days and one group was not, or where comparison groups were advised to stay in bed for different lengths of time. The main outcomes of interest were pain, functional status, recovery and return to work.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion, assessed the validity of included trials and extracted data. Investigators were contacted to obtain missing information.

MAIN RESULTS

Nine trials with a total of 1435 patients were included. Five trials met all four validity criteria and were assessed to have low risk of bias, while four trials were assessed to have moderate to high risk of bias. Four trials compared bed rest with advice to stay active, and overall the results were heterogeneous. Overall results from two high quality studies indicate no difference in pain intensity at three weeks follow-up [Standardized Mean Difference 0.0 (95%CI: -0.3, 0.2)], and a small difference in functional status in favour of staying active [Weighted Mean Difference 3.2 (on a 0-100 scale) (95%CI 0.6, 5.8)]. Two high quality trials reported no differences in pain intensity between two to three days of bed rest and seven days of bed rest. Another two high-quality trials found no differences between bed rest and exercises in pain intensity or functional status.

REVIEWER'S CONCLUSIONS

Bed rest compared to acvice to stay active will at best have small effects, and at worst might have small harmful effects on acute LBP. Differences in effects of advice to stay in bed compared with advice to stay active are small for patients with low back pain with or without sciatica. There is not an important difference in the effects of bed rest compared with exercises in the treatment of acute low back pain, or seven days compared with two to three days of bed rest in patients with low back pain of different duration with and without radiating pain.

Long-term disability and return to work among patients who have a herniated lumbar disc: the effect of disability compensation

BACKGROUND

Low-back problems are one of the most frequent reasons for disability compensation claims by workers. However, the effect of Workers' Compensation status on the long-term outcome for workers with sciatica has not been studied in detail, to our knowledge. Therefore, we believe that it is important to describe the long-term outcomes for patients who have herniation of a lumbar disc and sciatica according to the Workers' Compensation status at the time of the preoperative consultation.

METHODS

We conducted a prospective, observational study of patients who had sciatica and were seeking care from specialist physicians in community-based practices throughout Maine. Among 440 eligible patients, 199 were receiving Workers' Compensation at the time of entry into the study (baseline) and 241 were not. Three hundred and twenty-six patients (74 percent) completed questionnaires at the time of a four-year follow-up. The outcomes that we assessed included disability compensation and work status as well as relief from symptoms, functional status, and quality of life.

RESULTS

Patients who were receiving Workers' Compensation at baseline were more likely to be young, male, and employed as laborers. They reported worse functional status; however, the clinical findings for these patients were similar to those for patients who were not receiving Workers' Compensation. Patients who had been receiving Workers' Compensation at baseline were more likely to be receiving disability benefits at the time of the four-year follow-up compared with those who had not (27 percent of 133 compared with 7 percent of 189; p<0.001); however, they were only slightly less likely to be working at the time of the four-year follow-up (80 percent of 133 compared with 87 percent of 190; p = 0.09). Operative management did not influence these comparisons, but it decreased symptoms and improved functional status. Patients who had been receiving Workers' Compensation at baseline also had significantly less relief from symptoms and improvement in quality of life than patients who had not been receiving Workers' Compensation (all p<0.001). In multivariate models, Workers' Compensation status at baseline was an independent predictor of whether the patient would be receiving disability benefits after four years (odds ratio, 3.5; 95 percent confidence interval, 1.7 to 7.6) but was not an independent predictor of whether the patient would be working on a job for pay at the time of the four-year follow-up (odds ratio, 0.6; 95 percent confidence interval, 0.3 to 1.2).

CONCLUSIONS

Even after adjustment for the initial treatment of the sciatica and for other clinical factors, patients who had been receiving Workers' Compensation at baseline were more likely to be receiving disability benefits and were less likely to report relief from symptoms and improvement in quality of life at the time of the four-year follow-up than patients who had not been receiving Workers' Compensation at baseline. Nonetheless, most patients returned to work regardless of their initial disability status, and those who had been receiving Workers' Compensation at baseline were only slightly less likely to be working after four years. Whether or not they had been receiving Workers' Compensation at baseline, patients who had been managed with an operation reported greater relief from symptoms and improvement in functional status at the time of the four-year follow-up compared with patients who had been managed nonoperatively, even though the outcomes with regard to disability and work status in these two groups were comparable.

The efficacy of a risk factor-based cognitive behavioral intervention and electromyographic biofeedback in patients with acute sciatic pain. An attempt to prevent chronicity

STUDY DESIGN

An investigation of the efficacy of an individually scheduled, risk factor-based cognitive behavioral therapy and a standardized electromyographic biofeedback intervention in the prevention of chronicity in patients with acute sciatica and psychosocial risk factors for chronicity.

OBJECTIVES

To investigate the possibility of enhancing pain relief and preventing chronicity in patients with acute sciatica, based on a screening for psychosocial high-risk factors of chronification.

SUMMARY OF BACKGROUND DATA

Psychological interventions were evaluated mainly in patients with chronic low back pain. Numerous randomized trials have demonstrated their efficacy, whereas the amount of pain relief was found to be marginal.

METHODS

Subjective and behavioral outcome parameters were compared with the respective parameters in age-, gender-, and diagnosis-matched high- and low-risk patients. No additional behavioral treatment for in-patient medical therapy was offered to the patients. Outcome of these patients also was compared with that of a group of refusers of behavioral therapy. Psychological, functional, and behavioral variables were measured before and after treatment and at 3-, 6-, 12- and 18-month follow-up visits. Changes over time, group differences, and possible group x time interactions were analyzed by analysis of variance and nonparameteric comparisons.

RESULTS

Data analysis showed a statistically and clinically significant, beneficial effect of both behavioral interventions. However, risk factor-based cognitive behavioral therapy was superior to electromyographic biofeedback intervention with respect to pain relief and application for early retirement. The cognitive behavioral therapy showed a similar good outcome (e.g., 90% showed a clinical significant pain reduction) as the low-risk patients (83% pain reduction). High risk patients and refusers of therapy showed a poor outcome in pain (33% and 20% pain reduction, respectively), disability, and work performance.

CONCLUSIONS

Individually scheduled, risk factor-based cognitive behavior therapy could be a beneficial treatment modality, which can be offered, in addition to a medical treatment, to patients with acute sciatica and psychosocial high risk factors for chronicity. It may be an effective way to prevent chronification in these patients.