Percutaneous electrical nerve stimulation: an alternative to TENS in the management of sciatica

Sciatica is a common pain problem and current pharmacologic therapies have proven inadequate for many patients. The objective of this sham-controlled investigation was to compare a novel non-pharmacologic technique, percutaneous electrical nerve stimulation (PENS), to transcutaneous electrical nerve stimulation (TENS) in the management of the radicular pain associated with sciatica. Sixty-four consenting patients with sciatica due to lumbar disc herniation were treated with PENS, TENS and sham-PENS according to a randomized, single-blinded, cross-over study. All patients had been maintained on a stable oral non-opioid analgesic regimen for at least 6 weeks prior to entering the study. Each treatment modality was administered for a period of 30 min three times per week for 3 weeks, with 1 week 'off' between each modality. Both PENS and TENS treatments were administered using a stimulation frequency of 4 Hz. The pre-treatment assessment included the health status survey short form (SF-36), as well as visual analog scales (VAS) for radicular pain, physical activity and quality of sleep. The pain VAS was also repeated after each treatment session. At the end of each 3-week treatment block, the SF-36 was repeated. After receiving all three treatment modalities, a global assessment questionnaire was completed. Both PENS (42%) and TENS (23%) were significantly more effective than the sham (8%) treatments in decreasing VAS pain scores. The daily oral analgesic requirements were also significantly reduced compared to the pre-treatment values with PENS (P<0.01) and TENS (P<0.05). However, PENS was significantly more effective than TENS (and sham-PENS) in improving physical activity and quality of sleep. The SF-36 evaluation confirmed the superiority of PENS (versus TENS and sham-PENS) with respect to post-treatment functionality. In the overall assessment, 73% of the patients reported that PENS was the most desirable modality (versus 21% for TENS and 6% for sham-PENS). Finally, 71% of the patients stated that they would be willing to pay extra to receive PENS therapy compared to 22% and 3% for TENS and sham-PENS, respectively. In this sham-controlled study, we concluded that PENS was more effective than TENS when administered at a stimulation frequency of 4 Hz in providing short-term pain relief and improved functionality in patients with sciatica.

[Aspects of conservative sciatic pain therapy]

Successful multimodal conservative treatment of sciatic pain will prevent unfavorable results of life discectomy and accelerates the natural course. In assessment of modalities of conservative treatment of sciatic pain, somatic and psychosomatic aspects have to be considered. Severe neurological deficits caused by lumbar disc herniation have to be treated surgically. Conservative treatment of sciatic pain follows the etiopathogenetic hypothesis of a centrally triggered and radicularly terminated inflammation; it reflects the biopsychosocial paradigm. Inflammatory alterations in the disc and psychosocial peculiarities of the patients prove this disease model. Conservative treatment of sciatic pain does not determine its, but works by the combined operation of different but etiopathogenetic or scientifically efficient means. Somatic therapy aims at blocking the inflammatory cascade by peridural and systemic antiphlogistic drugs, sufficiently applied analgesics and temporally limited bedrest. Physiotherapy and sports therapy for remobilization will follow. Psychosomatic therapy works through relaxation, support and interpretation. Physiotherapy, relaxation and verbal intervention work prophylactically, too. The patient-doctor relationship plays a crucial role in conservative treatment of sciatic pain.

A clinical diagnosis of inadvertent epidural administration of potassium chloride

We present a case of accidental epidural administration of potassium chloride, which was diagnosed by clinical signs. The genesis of symptoms and signs following such administration is discussed and compared with other published reports.

[Chiropractic in general and in low back pain]

The practice of chiropractic was for many years regulated by "The Quack Act" in Norway, and the numbers of chiropractors decreased year by year. They are now authorized health care practitioners with academic training; most Norwegian students attending courses in chiropractic or clinical biomechanics go to European universities. An international council ensures reciprocity and a quality assured academic programme in all recognized colleges of chiropractic. Recent research have broadened our understanding of the biomechanical interrelationship between the nervous system, the musculature and the skeletal articulations. In the early 1990s, several studies documented favourable effect of chiropractic treatment of low back disorders. These studies are now substantiated by new studies, especially concerning cost-effectiveness. Several reports also give evidence that chiropractic manipulation is beneficial especially in combination with light exercise. There are conflicting results concerning the efficacy of varying types of exercise programmes. Patients may benefit from increased cooperation between medical doctors and chiropractors. Most acute low back syndromes should be assessed by the chiropractor in order to prevent chronic illness.

Low back pain. Evaluation and management in the primary care setting

The primary care physician plays a major role in the identification of low back pain and the entry of the patient into the health care system. Acute low back pain remits within a short period of time in most patients, and major diagnostic studies are not required. If the pain persists beyond the treatment parameters of the primary care physician, consultation is necessary. A basic component of the initial evaluation is the identification of myofascial syndromes that mimic so-called root syndromes. Further, low back pain in the population at large is not usually a surgical problem, and the chances of there being significant pathology requiring surgical or other forms of intervention may be less than 1% of those affected. When the initial attempts at treatment fail, the patient should be referred to a multidisciplinary comprehensive pain center so as to avoid or limit chronicity, the earlier, the better. Practitioners should feel comfortable in asking the centers to which they make a referral for outcome data. If these are not available, the choice should be made elsewhere. Low back pain per se is in the majority not a neurologic problem, an orthopedic problem, or a neurosurgical problem, so that consultation with these groups, unless there are strong suspicions otherwise, has limited value. The criteria for selection and referral of patients to multidisciplinary pain centers have been presented, including specific considerations for the geriatric age group. The overwhelming cost of low back pain to the economy can be decreased along with suffering and the adverse impact that pain has on all social strata.

Is it possible to predict the efficacy at discharge of inhospital rheumatology department management of disk-related sciatica? A study in 150 patients

OBJECTIVES

To identify criteria for predicting the outcome at discharge in patients scheduled for inhospital treatment of disk-related sciatica.

PATIENTS AND METHODS

We studied 150 rheumatology department patients admitted for disk-related sciatica with a mean duration of 88 +/- 127 days to determine the impact on treatment outcomes of 50 parameters.

RESULTS

After complete bed and 2.2 +/- 1.1 epidural glucocorticoid injections during a mean hospital stay of 9.9 +/- 4.3 days, 80% of patients reported either complete or partial pain relief (19% and 61%, respectively). The remaining 20% reported little (9%) or no (11%) change. Surgery was performed in 13% of cases. A tighter straight-leg raising test angle was correlated with treatment failure (P = 0.01). Complete bed rest duration prior to admission was shorter in the 80% of responders (P = 0.036) than in the 20% of nonresponders; in the overall population, patients spent on average 64% +/- 33% of daytime hours in bed. Patient predictions about their own outcomes were unreliable (P = 0.926). Patients who believed strongly that sciatica requires surgical treatment were more likely to be nonresponders (P = 0.06), as were patients with a family history of surgically-treated sciatica (P = 0.055). Outcomes were not correlated with any of the other parameters studied, including sciatica duration (P = 0.13), bedrest duration prior to admission (P = 0.52; mean duration, 18 +/- 29 days), the specialty of the physicians seen, investigations done prior to admission, or a history of sciatica (noted in 65% of cases and treated surgically in 16%).

CONCLUSIONS

Eighty percent of patients benefited from their hospital stay. Patient opinions on the merits of nonsurgical and surgical treatments in their own case were not correlated with their own outcomes. A tight straight leg-raising test angle was correlated with a poorer outcome. Neither sciatica duration nor rest duration prior to admission had an influence on outcome. Absence of complete bed rest prior to admission was correlated with a greater likelihood of a therapeutic benefit from the hospital stay.

Lack of effectiveness of bed rest for sciatica

BACKGROUND AND METHODS

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.

RESULTS

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.

CONCLUSIONS

Among patients with symptoms and signs of a lumbosacral radicular syndrome, bed rest is not a more effective therapy than watchful waiting.

[A case of Guillain-Barrè syndrome with severe sciatica preceding motor paralysis in the lower extremities]

A 62-year-old man was referred to our clinic for a three-day history of intractable sciatic pain. The pain was so severe that he could not sleep for days. Initially there was no neuronal sign except for the pain, nor any abnormality in lumbar CT and MRI. Cerebrospinal fluid sampled on the third hospital day revealed elevated protein (192 mg.dl-1) with minimal cells. On the 4th hospital day motor weakness of lower extremities appeared and he developed complete flaccid paraplegia in a week without loss of sensation. He was diagnosed as Guillain-Barrè syndrome. For the relief of this pain, intermittent injection of 4 ml 0.25% bupivacaine from lumbar epidural catheter was started on the admission day. By using patient controlled analgesia system, we could treat his repetitive demand timely and well control the pain. The leg weakness started to recover slowly from the 13th hospital day and at the same time the pain started to diminish rapidly in a few days. From the 20th hospital day he started to have rehabilitation in walking and recovered completely in two months without complication. We should remember that sudden onset of severe pain is one of early symptoms of Guillain-Barrè syndrome.

Injection of the piriformis muscle by fluoroscopic and electromyographic guidance

BACKGROUND

There is not a universally accepted single technique for injection of the piriformis muscle that has validated exact placement of the needle tip within the piriformis muscle.

OBJECTIVE

We sought a methodology that would precisely document needle placement within the piriformis muscle that is reliable, relatively uncomplicated, and reproducible.

METHODS

Patients with piriformis syndrome underwent injections of the piriformis muscle under fluoroscopic and electromyographic guidance. This technique used electrophysiological confirmation of needle placement within the piriformis muscle and image-guided identification of the piriformis muscle with radiopaque contrast media under fluoroscopy.

RESULTS

Using this methodology, injections on 17 occasions in 11 patients resulted in needle placement within the piriformis muscle.

Inhospital management of common lumbosciatic syndrome. An opinion survey among French rheumatologists

To determine which treatments are most commonly offered to patients younger than 70 years of age admitted for uncomplicated lumbosciatica suggestive of disk herniation, we sent a 43-item questionnaire to 106 rheumatology departments in France. The questionnaire collected information on hospital stay duration, modalities of rest, drug treatments, local glucocorticoid injections, physical treatments, sick leave duration and advice given to the patients. The response rate was 77% (84 questionnaires). Substantial variations were found across departments. Hospital stay duration ranged from five to 20 days and nonsteroidal antiinflammatory drug treatment duration from five to 30 days. Local glucocorticoid therapy was given as one to four injections at intervals of two to seven days. Spinal traction was used in 38% and a corset in 50% of study centers. Neither was there any consensus regarding immediate or delayed physiotherapy. Most respondents recommended bedrest for no longer than 15 days, a nonsteroidal antiinflammatory drug, a level I or II analgesic, local glucocorticoid injections and, in the event of persistent pain at the end of the hospital stay, a lumbar corset.

[Osseous avulsion of the ischio-crural muscle group with concomitant sciatica]

Avulsion fractures of the ischial tuberosity are rare. They are often caused by a typical "splits"-like accident. In general the patients feel sudden severe pain in the buttock with localized tenderness in the region of the ischial tuberosity, rarely in combination with sciatic nerve irritation. According to the functional anatomy, flexion of the knee and extension of the hip may be impaired. Roentgenograms often reveal no abnormality and show no evidence of fracture. Therefore, inadequate therapy because of missed diagnosis can result in avoidable persistent pain. We report on a 42-year-old man with an avulsion fracture of the ischial tuberosity. The epidemiology, symptoms, including irritation of the sciatic nerve, differential diagnoses, diagnostic procedures and therapy are presented in detail.

Manipulative therapy in lower back pain with leg pain and neurological deficit

OBJECTIVE

To discuss a case of sciatica associated with lower back pain that originates in a disc. We discuss the use of manipulative therapy as a conservative approach and compare it with other conservative methods and with surgery.

CLINICAL FEATURES

The patient suffered from lower back and left leg pain that had increased in severity over a 6-day period. There was decreased sensation in the dorsum of the left foot and toes. Computed tomography demonstrated the presence of a small, contained disc herniation.

INTERVENTION AND OUTCOME

The patient was initially treated with ice followed by flexion-distraction therapy. This was used over the course of her first three visits. Once she was in less pain, side posture manipulation was added to her care. Nine treatments were required before she was released from care.

CONCLUSION

We need a nonsurgical, conservative approach to treat lower back pain with sciatica as an alternative to and before beginning the more aggressive, and potentially hazardous, surgical treatment. There is some support for the idea that lumbar disc herniation with neurological deficit and radicular pain does not contraindicate the judicious use of manipulation. Although significant questions remain for the evaluation and treatment of lumbar radiculopathy (sciatica) with disc herniations, there is ample evidence to suggest that a course of conservative care, including spinal manipulation, should be completed before surgical consult is considered.

Catamenial mononeuropathy and radiculopathy: a treatable neuropathic disorder

OBJECT

The aim of this study was to investigate the indications and treatment options in patients with lower-extremity neuropathies and radiculopathies caused by endometriosis.

METHODS

The authors identified five patients whose symptoms included catamenial pain, weakness, and sensory loss involving the sciatic and femoral nerves and multiple lumbosacral nerve roots. Radiographic studies supported the diagnosis of catamenial neuropathy or radiculopathy, but definitive diagnosis depended on surgical and pathological examination. Treatment of symptoms, including physical therapy and a course of antiinflammatory or analgesic medication, was not helpful. Patients responded favorably to hormonal therapy. Laparoscopy or open exploration for extrapelvic lesions was performed for diagnosis or for treatment when hormone therapy failed. Pain and sensory symptoms responded well to therapy. Weakness improved, but never recovered completely.

CONCLUSIONS

Catamenial neuropathy or radiculopathy should be considered when evaluating reproductive-age women with recurring focal neuropathic leg pain, weakness, and sensory loss.

Vascular complication involving the conus medullaris or cauda equina after vertebral manipulation for an L4-L5 disk herniation

A case of injury to the cauda equina or conus medullaris after lumbar vertebral manipulation is reported. In contrast to all other previously reported cases, no migrated disk fragment was demonstrated. Similar to experience at the cervical spine, lumbar vertebral manipulation may carry a risk of vascular injury. The neurological manifestations in our patient were consistent with compression of the Desproges-Gotteron artery by a small L4-L5 disk herniation.

Common peroneal nerve block for sciatica

The effectiveness of common peroneal nerve block for lumbar disc herniation was evaluated in a double blind study. Common peroneal nerve block was performed near the fibular head in nine patients using 2% lidocaine and in 10 patients using saline. The average pain scale score decreased from 3.1 to 0.6 in the lidocaine group, whereas it decreased from 3.0 to 2.6 in the placebo group. The average result in the straight leg raising test increased from 61 degrees to 84 degrees in the lidocaine group, but from 44 degrees to 50 degrees in the placebo group. Lower leg pain lessened more in the lidocaine group than in the placebo group. The finding that lower leg pain disappeared or decreased with a lidocaine block at a site far distal to the lumbar lesion suggests that impulses that are transmitted distal to the lesion may be important for the generation of sciatic radicular pain.

A prospective analysis of magnetic resonance imaging findings in patients with sciatica and lumbar disc herniation. Correlation of outcomes with disc fragment and canal morphology

STUDY DESIGN

A two-part observational study. In Part 1, consecutive lumbar magnetic resonance imaging scans in patients with sciatica meeting enrollment criteria were prospectively and blindly analyzed by a set protocol. In Part 2, further clinical findings at the time of the magnetic resonance imaging were obtained by retrospective chart review and outcome assessment done at follow-up of more than 2 years.

OBJECTIVES

To determine the quantitative magnetic resonance findings of disc and canal measures in patients with sciatica and to analyze the predictive values of these magnetic resonance imaging and clinical variables on outcomes.

METHODS

Part 1: Consecutive patients with a primary diagnosis of sciatica who came to lumbar magnetic resonance imaging were enrolled, and magnetic resonance imaging dimensions of discs and canal at the herniated level were collected. Part 2: Of 186 patients in Part 1, 135 were followed for more than 2 years; 87 were treated conservatively, and 48 were treated surgically. Outcomes were judged on satisfaction, activity level, medication intake, and reported pain at follow-up (mean, 2.6 years).

RESULTS

Part 1: Wide ranges of disc and canal measurements were seen in all parameters. Significant differences in all magnetic resonance parameters were noted between male and female patients. Men had proportionately greater canal compromise by the affected disc than women. Positive sciatic tension signs and short duration of symptoms correlated with large disc herniation. Right-sided symptomatic herniations were usually larger than left. Part 2: At follow-up, predictors of outcome were determined independently for the surgery and the nonoperative groups. In the nonoperative group, a shorter duration of sciatica was the most significant predictor of a good outcome (P = 0.0018). Moreover, a duration of symptoms less than 6 months, no involvement with litigation, and younger age were also correlated with a favorable outcome. The only magnetic resonance parameter associated with good outcome was a small ratio of disc hemiarea to remaining canal hemiarea (P = 0.045). For the surgical group, a larger anteroposterior disc length was the most significant independent predictor of a positive outcome (P < 0.0001). Larger ratios of disc area to canal area are also significantly associated with good outcomes (P < 0.0001), as are large disc areas and small remaining canal areas. Large right-left canal widths and small disc widths are also identified as predictors of a favorable outcome. Of the clinical parameters, concurrent medical illness, workers' compensation involvement, and female gender appear to be the most significantly correlated with poor outcome. All fair or poor surgical outcomes were in patients with smaller (< 6 mm) disc herniations.

CONCLUSIONS

Quantitative measurements by magnetic resonance imaging of disc and canal morphology of 188 patients with sciatica indicate a wide range of herniation and canal sizes, with significant differences between men and women. In a cohort of 135 patients followed for more than 2 years, demographic and clinical features appeared to predict outcomes of nonoperative treatment, whereas morphometric features of disc herniation and the spinal canal seen on magnetic resonance imaging were much more powerful predictors of surgical outcomes.

The disc at risk in athletes: perspectives on operative and nonoperative care

Low back pain is the most common cause of disability in individuals below the age of 45 and the third most common cause of disability overall. Although acute back pain is generally felt to have a high probability of spontaneous resolution, the high recurrence rate of low back pain challenges the notion that resolution of symptoms is accompanied by restitution of function. Athletes who have lumbar spine dysfunction represent a particular challenge to the treating physician due to their high levels of activity and expectation of return to sport. Injuries to the intervertebral disc in the lumbar spine are a particular subset of spine injury. Management of intervertebral disc injuries, which is the focus of this section, is fraught with controversy. Although the majority of intervertebral disc injuries can be treated conservatively, the decision to follow an aggressive conservative versus surgical course in any given athlete must be made on an individual case basis.

[Sciatica caused by avulsion of the vertebral limbus in children]

PURPOSE OF THE STUDY

Sciatica is very rare in children. We report a particular from due to traumatic avulsion of the posterior vertebral limbus. The purpose of this study was to give the principal clinical and radiological aspects of this entity and to discuss the treatment which should be different from that of common adult disk herniation.

MATERIALS

From 1980 to 1992, 10 children were examined for a sciatica (7 boys and 3 girls aged from 10 years 1 month to 15 years 2 months). Sciatica appeared in all cases during sport activities and sometimes after a sport accident. Lumbar spine stiffness was encountered in all cases. Radiculalgia was unilateral in 7 cases, bilateral in 3 cases, in L5 territory in 3 and S1 in 7 cases. 4 children had deficitary neurological signs: 3 abolitions of achilles reflex, 1 weakness of foot dorsi-flexors. Standard x-rays showed in 4 cases the avulsed fragment in the vertebral canal. Spondylosis was encountered in 3 cases and spondylolisthesis in one case. Diagnosis was possible in all cases with CT Scan, M.R.I., when done showed a normal disk signal. Three children were managed by a conservative treatment by rest or brace. Seven had a surgical treatment: resection of the avulsed fragment in 6 and total diskectomy in one. The mean follow-up was five years (2 to 8 years).

RESULTS

There was no complication. At last follow-up all children had a good result without sciatica recurrence.

DISCUSSION

Many factors allow us to think that avulsion of the vertebral rim in children is of traumatic origin. CT Scan is the best exploration for this particular lesion. It enabled evaluation of fragment volume and location. Magnetic resonance imaging showed uninjured disks. Removal of the avulsed fragment without diskectomy seems possible in children.

Focus issue on lumbar disc herniation: macro- and microdiscectomy

This paper is based on a review, analysis, and discussion of the extensive literature on indications, technique, and complications of discectomy (macro and micro) for lumbar disc herniation. Outcomes for lumbar discectomy for disc herniation depend on patient selection. Short-term results of discectomy are excellent when there is agreement between the clinical presentation and imaging studies. Long-term results of surgery are only slightly better than conservative measures and the natural history of a lumbar disc herniation. A review of the literature reveals success rates for lumbar discectomy ranging from 80-96%. The outcome of lumbar discectomy does not appear to be affected by the use of a microscope and depends more on patient selection than on surgical technique.

Methods used to develop clinical guidelines in France. The example of common lumbosciatic syndrome

A number of Regulatory Medical References, or criteria for quality health care, have been worked out in France by a committee of physicians' union and national health insurance agency representatives, based on clinical guidelines developed using predefined methods. For each guideline, the level of evidence was evaluated, and when this level was inadequate a strong professional consensus was sought. For common lumbosciatic syndrome, the ANDEM (Agence Nationale pour le Développment de l'Evaluation Médicale, or national agency for the development of medical evaluation) worked with a multidisciplinary study group (specialists and nonspecialists, physicians from teaching hospitals, regional hospitals and private practices, primary care practitioners and specialists) whose members were from different areas of France. A computerized and manual literature search was conducted. The project director and the study group chairperson reviewed each document using predefined criteria to evaluate the methodology and level of scientific evidence. When this level was inadequate, a strong consensus expressing an opinion accepted by the medical profession was looked for. Bold type was used to indicate data resting on very high levels of evidence. The committee of physicians' union and national health insurance agency representatives used these documents to select a number of situations for which "regulatory medical references" would be useful. Each reference was written as one or a few sentences starting by "It is inappropriate to...". The study group found that subjectivity and pragmatism significantly influence the selection of diagnostic and therapeutic strategies for common lumbosciatic syndrome. The review and discussion of the high-quality literature on this condition led the study group members to modify their opinions and facilitated the development of a consensus. The group noted the paucity of scientific data on the natural history of common lumbosciatic syndrome and on the value of drug therapy and other commonly used therapeutic modalities.

The piriformis syndrome

Piriformis syndrome is an often misdiagnosed cause of sciatica, leg, or buttock pain, and disability. The sciatic nerve may be compressed within the buttock by the piriformis muscle, with pain increased by muscular contraction, palpation, or prolonged sitting. A thorough medical history and physical examination are essential to proper diagnosis. Diagnostic testing may be used to differentiate piriformis syndrome from other causes of sciatica, lower extremity weakness, and pain. This article reviews the pathophysiology and management of piriformis syndrome.

The Maine Lumbar Spine Study, Part II. 1-year outcomes of surgical and nonsurgical management of sciatica

STUDY DESIGN

The Maine Lumbar Spine Study is a prospective cohort study of patients recruited from the practices of orthopedic surgeons, neurosurgeons, and occupational medicine physicians throughout Maine.

OBJECTIVE

To assess 1-year outcomes of patients with sciatica believed to be due to a herniated lumbar disc treated surgically or nonsurgically.

SUMMARY OF BACKGROUND DATA

Lumbar spine surgery rates vary by geographic region and may reflect uncertainty about optimal clinical use.

METHODS

Eligible consenting patients participated in a baseline interview performed by study personnel and then were mailed follow-up questionnaires at 3, 6, and 12 months. Clinical data were obtained from a physician questionnaire. Outcomes included patient-reported symptoms of leg and back pain, functional status, disability, quality of life, and satisfaction with care.

RESULTS

Five hundred seven patients with sciatica, 275 treated surgically and 232 treated nonsurgically initially, were enrolled. Surgically treated patients, on average, had more severe symptoms and had more severe physical and imaging findings than nonsurgically treated patients at entry. Although few surgically treated patients had mild symptoms and few nonsurgically treated patients had severe symptoms, about half in each treatment group had symptoms that fell into a moderate category. At the 1-year evaluation, improvement in symptoms, functional status, and disability were found in both treatment groups. However, surgically treated patients reported significantly greater improvement. For the predominant symptom, either back or leg pain, 71% of surgically treated and 43% of nonsurgically treated patients reported definite improvement (P < 0.001). This effect was even greater after adjustment for differences between treatment groups at entry (relative odds of definite improvement, 4.3; P < 0.001). For patients with moderate symptoms and abnormal physical examination findings, surgical treatment also resulted in greater improvement than nonsurgical treatment. However, there was little difference in the employment or workers' compensation status of patients treated surgically versus nonsurgically (5% vs. 7% unemployed at 1-year follow-up if employed at entry [P = 0.68]; 46% vs. 55% receiving workers' compensation at 1-year follow-up if receiving it at entry [P = 0.30] for surgical and nonsurgical management, respectively). For patients with mild symptoms, the benefits of surgical and nonsurgical treatment were similar.

CONCLUSIONS

Although surgically treated patients were on average more symptomatic at entry, there was substantial overlap in symptoms between surgically treated and nonsurgically treated patients. Surgically treated patients with sciatica reported substantially greater improvement at 1-year follow-up. However, employment and compensation outcomes were similar between the two treatment groups, and surgery appeared to provide little advantage for the subset of patients with mild symptoms. These results should be interpreted cautiously, because surgical treatment was not assigned randomly. Long-term follow-up will determine if these differences persist.

The Maine Lumbar Spine Study, Part I. Background and concepts

STUDY DESIGN

This paper describes the background and factors that led to the development and implementation of the Maine Lumbar Spine Study, a prospective cohort study of patients undergoing surgical and nonsurgical treatment of herniated lumbar disc with sciatica and symptomatic spinal stenosis.

OBJECTIVES

To define the factors leading to the study and the methods of designing and implementing a community-based effectiveness study to evaluate the outcomes of herniated lumbar intervertebral disc and spinal stenosis.

SUMMARY OF BACKGROUND DATA

Variations in the utilization of surgery for these conditions and physicians' uncertainty regarding the best way to manage them resulted in support of a community-based study of the effectiveness of treatment alternatives.

METHODS

A prospective cohort design was used. Methods of patient enrollment, data collection, management, and analysis are described. An innovative method of ascertaining the representativeness of the enrolled versus nonenrolled patient population is presented.

RESULTS

The importance of developing community-based networks of physicians is discussed.

CONCLUSIONS

These networks play an important role in analyzing practice pattern variations and in stimulating and participating in effectiveness research. Because effectiveness studies must be conducted at the community level, mechanisms must be developed with which to support and implement these efforts.

Application of outcomes research in occupational low back pain: the Maine Lumbar Spine Study

Outcomes research represents an expansion of traditional clinical research to include issues of cost and quality of care in usual clinical practice, emphasizing outcomes that matter most to patients. In low back disorders, outcomes research has focused on the lack of reliable information to support much of clinical practice and has demonstrated marked variability in the treatment of these common problems. The Maine Lumbar Spine Study represents an example of an outcomes research study to investigate the treatment of patients with sciatica in usual clinical practice. Because low back symptoms are a frequent cause of occupational disability, Workers' Compensation patients were explicitly oversampled. Baseline features were significantly different in those patients who were receiving Workers' Compensation versus those who were not. Efforts to compare outcomes by disability status need to control for these differences. Whereas most Workers' Compensation patients were still receiving disability compensation regardless of treatment at 6 months, patients who were treated surgically were more likely to have come off disability and returned to work than nonsurgically treated patients. Long-term follow-up is necessary to determine whether these differences persist.

Spondylolisthesis with sciatica. Magnetic resonance findings and chemonucleolysis

Fifteen patients with bilateral lumbar isthmic spondylolisthesis and unilateral sciatica were examined with magnetic resonance imaging. All patients had a disc protrusion at the level of the spondylolisthesis. Nine patients had a central herniated disc that caused dural sac deformation; in 6 of these patients there was extension to the disc tissue into the foramen. In 5 patients there was no clear dural sac deformation, but there was a foraminal disc protrusion that caused nerve root compression. In 1 patient there was a hernia lateral to the foramen. In none of the patients was there evidence of compression by bony elements. No abnormalities on adjacent levels were found. All 15 patients were treated with chemonucleolysis. There were no complications. A followup study was done after 19 months (range, 10-42 months). The result was rated as good or excellent in 10 of 12 patients with a spondylolisthesis of L5 and in 1 of 3 patients with a spondylolisthesis of L4. Magnetic resonance imaging showed a decrease in dural sac deformation in 4 patients, no clear decrease in 3, and a slight increase in 2. There were no distinct foraminal changes in 9 of 11 patients.

Chemonucleolysis

Even with a history of controversy and troubling complications, chymopapain has endured the test of time to show 30 years of clinical success in the treatment of herniated nucleus pulposus. Strict attention to indications, contraindications, and technique ensures safety and efficacy of treatment. A trend to decreased dosage may result in less postinjection spasm. Between 1982-1991, 121 adverse events in 135,000 patients were reported to the Food and Drug Administration and investigated. Seven cases of fatal anaphylaxis, 24 infections, 32 bleeding problems, 32 neurologic events, and 15 miscellaneous occurrences were found. Overall mortality rate was 0.019%. All categories were of lesser incidence than complications with laminectomy. Long-term results show that improvement after chemonucleolysis is maintained, whereas the outcome after laminectomy is reported to deteriorate with time. Cost savings with chemonucleolysis over laminectomy are largely a matter of shorter hospitalization. A protocol for cervical chemonucleolysis is being developed in the United States after good results have been shown in Spain and France. Other enzymes continue under investigation, but chymopapain remains the standard to which they are compared.

Efficiency of discography followed by chemonucleolysis in the treatment of sciatica

One hundred and twenty-eight patients underwent discography in our department over a period of 3 years. Eighty-four of them were treated by chemonucleolysis. All the patients were punctured by a postero-lateral approach of the intervertebral disc under fluoroscopy. Although several contraindications to chemonucleolysis are known, in our study, only one case of spondylodiscitis was noted. Overall success rate was 72.6%. Twenty-three patients (27.4%) experienced similar or increased pain after treatment.

Specificity of diagnostic nerve blocks: a prospective, randomized study of sciatica due to lumbosacral spine disease

Temporary nerve blocks using local anesthetic are employed extensively in the evaluation of pain problems, particularly lumbosacral spine disease. Their specificity and sensitivity in localizing anatomic sources of pain have never been studied formally, however, and so their diagnostic and prognostic value is questionable. There have been anecdotal reports of relief of pain by temporary blocks directed to areas of pain referral, as opposed to areas of documented underlying pathology; but there has been no study to define the frequency or magnitude of this effect. We have examined the specificity and sensitivity of a battery of local anesthetic blocks in a series of 33 patients with a chief complaint of sciatica, attributable in all cases to spinal disease (radiculopathy, with some clinical features of arthropathy). As determined by blinded patient analog ratings in randomized sequence, three different nerve blocks were significantly more effective than control lumbar subcutaneous injection of an identical volume of 3 ml of 0.5% bupivacaine (P < 0.05). Not only paraspinal lumbosacral root blocks and medial branch posterior primary ramus blocks (at or proximal to the pathology), but also sciatic nerve blocks (distal or collateral to the pathology) produced temporary relief in a majority of patients. This confirmed the study hypothesis that false positive results are common, and specificity is low. For sciatic nerve blocks, specificity was between 24% and 36%. Patterns of responses specific to the established diagnosis of radiculopathy (i.e., root block most effective) had sensitivities between 9% and 42%. Statistical analysis of clinical and technical prognostic factors revealed that the only association with pain relief by any block were the effects of other blocks. The strongest association was between relief by sciatic nerve block and relief by medial branch posterior primary ramus (facet) block (P = 0.001, odds ratio 16.0). There were no associations between the results of blocks and clinical findings (history, physical examination, diagnostic imaging) in these patients, chosen for their homogeneous clinical presentation and absence of functional signs. Our findings indicate a limited role for uncontrolled local anesthetic blocks in the diagnostic evaluation of sciatica and referred pain syndromes in general. Negative blocks or a pattern of responses may have some predictive value, but isolated, positive blocks are non-specific. This lack of specificity may, however, be advantageous in therapeutic applications.

Diagnosis and management of low back pain and sciatica

Acute low back pain with associated sciatica is usually a benign, self-limited disorder. Appropriate medical treatment may include passive forms of physical therapy, including McKenzie exercises, manipulation, medication and therapeutic injections. After pain is controlled, the patient should be taught self-management techniques, including exercises and ergonomic protection of the spine. Evidence is increasing that exercise programs are effective, although the optimal regimen has yet to be defined and may vary from patient to patient. Chronic low back pain is a complex disorder that must be managed aggressively with a multidisciplinary approach that addresses physical, psychologic and socioeconomic aspects of the illness. Self-administered traction, corsets, medications and other treatment methods may prove to be useful adjuncts to an active program of exercise and education that promotes functional restoration.

[Effectiveness of conservative and surgical treatment of lumboischiadic syndrome]

BACKGROUND

Hitherto performed retrospective studies of conservative and surgical treatment of compressive radicular lumboischiadic syndrome did not provide a clear answer to the question which procedure cures the disease more effectively. The reason is that severe types of the disease treated by surgery were compared with therapeutic results of milder forms treated conservatively. The authors compared therefore the effectiveness of both therapeutic procedures in a prospective study with a random selection of patients as regards the therapeutic procedure.

METHODS AND RESULTS

In two groups--first group comprising 100 patients with the global syndrome and second group comprising 64 patients with the pure syndrome--the authors enlisted the patients by random selection for conservative or surgical treatment. Early results were assessed three months after treatment. Satisfactory results (cure) were achieved in 50% of the operated patients with the global syndrome, compared with 23.81% treated conservatively (p < 0.01), and improvement was recorded in 77.77% operated patients as compared with 58.69% conservatively treated patients (p < 0.05). In the group with the pure syndrome satisfactory results were achieved in 68.75% operated patients as compared with 21.87% conservatively treated patients (p < 0.001) and improvement in 81.25% patients as compared with 53.12% conservatively treated patients (p < 0.01).

CONCLUSIONS

The investigation proved a statistically significantly greater effectiveness of the surgical method of treatment of compressive radicular lumboischiadic syndrome as compared with conservative treatment. The second finding was that both methods have a relatively low effectiveness as regards, complete recovery. It is necessary to seek methods to increase the effectiveness of both therapeutic procedures, in particular clearly more effective surgical treatment.