Influence of gender and other prognostic factors on outcome of sciatica

Lumbar Disc Herniation—the Significance of Symptom Duration for the Indication for Surgery

BACKGROUND

Lumbar disc surgery is among the more common spinal procedures. In this paper, we report the current treatment recommendations for patients with symptomatic disc herniation.

METHODS

This review is based on pertinent publications retrieved by a selective literature search in PubMed using the terms [timing] AND [lumbar disc herniation], supplemented by other relevant articles and guidelines.

RESULTS

Symptoms resolve in 60% to 80% of patients with herniated discs in 6-12 weeks, and in 80% to 90% over the long term (≥ 1 year). According to the guidelines, 6-12 weeks of conservative treatment are recommended in the absence of significant neu - rologic deficits. Early surgery is indicated in case of worsening pain or new onset of neurologic deficits. Lumbar disc herniation associated bladder or bowel dysfunction (cauda equina syndrome) is considered an absolute surgical emergency that requires immediate decompression (within 24 to 48 hours). Patients with severe motor deficits (MRC ≤ 3/5) benefit from early intervention and should be offered surgery within three days, if possible, for the best chance of recovery. The degree of weakness and the duration of symptoms have been identified as risk factors for incomplete recovery. Early surgery can be considered in patients with mild paresis (MRC 4/5) in case of functional impairment (e.g., quadriceps paresis).

CONCLUSION

Longer symptom duration and lower motor scores are associated with worse outcome and a lower chance of neurologic recovery. The recovery rate for motor deficits ranges from 33% to 75%, depending on the timing and modality of treatment as well as the motor score.

Practice variation in surgical treatment for lumbar degenerative disc disease: exploring regional and hospital factors influencing surgical rates

The presence of significant, unwarranted variation in treatment suggests that clinical decision making also depends on where patients live instead of what they need and prefer. Historically, high practice variation in surgical treatment for lumbar degenerative disc disease (LDDD) has been documented. This study aimed to investigate current regional variation in surgical treatment for sciatica resulting from LDDD. We conducted a retrospective, cross-sectional analysis of all Dutch adults (>18 years) between 2016 and 2019. Demographic data from Statistics Netherlands were merged with a nationwide claims database, covering over 99% of the population. Inclusion criteria comprised LDDD diagnosis codes and relevant surgical codes. Practice variation was assessed at the level of postal code areas and hospital service areas (HSAs). Multivariable logistic regression analysis was employed to identify variables associated with surgical treatment. Among the 119,148 hospital visitors with LDDD, 14,840 underwent surgical treatment. Practice variation for laminectomies and discectomies showed less than two-fold variation in both postal code and HSAs. However, instrumented fusion surgery demonstrated a five-fold variation in postal code areas and three-fold variation in HSAs. Predictors of receiving surgical treatment included opioid prescription and patient referral status. Gender differences were observed, with males more likely to undergo laminectomy or discectomy, and females more likely to receive instrumented fusion surgery. Our study revealed low variation rates for discectomies and laminectomies, while indicating a high variation rate for instrumented fusion surgery in LDDD patients. High-quality research is needed on the extent of guideline implementation and its influence on practice variation.

1. Lumbosacral radicular pain

INTRODUCTION

Patients suffering lumbosacral radicular pain report radiating pain in one or more lumbar or sacral dermatomes. In the general population, low back pain with leg pain extending below the knee has an annual prevalence that varies from 9.9% to 25%.

METHODS

The literature on the diagnosis and treatment of lumbosacral radicular pain was reviewed and summarized.

RESULTS

Although a patient's history, the pain distribution pattern, and clinical examination may yield a presumptive diagnosis of lumbosacral radicular pain, additional clinical tests may be required. Medical imaging studies can demonstrate or exclude specific underlying pathologies and identify nerve root irritation, while selective diagnostic nerve root blocks can be used to confirm the affected level(s). In subacute lumbosacral radicular pain, transforaminal corticosteroid administration provides short-term pain relief and improves mobility. In chronic lumbosacral radicular pain, pulsed radiofrequency (PRF) treatment adjacent to the spinal ganglion (DRG) can provide pain relief for a longer period in well-selected patients. In cases of refractory pain, epidural adhesiolysis and spinal cord stimulation can be considered in experienced centers.

CONCLUSIONS

The diagnosis of lumbosacral radicular pain is based on a combination of history, clinical examination, and additional investigations. Epidural steroids can be considered for subacute lumbosacral radicular pain. In chronic lumbosacral radicular pain, PRF adjacent to the DRG is recommended. SCS and epidural adhesiolysis can be considered for cases of refractory pain in specialized centers.

Prognosis of Patients With Neuropathic Low Back-Related Leg Pain: An Exploratory Study Using Prospective Data From UK Primary Care

This prospective cohort study investigates the prognosis of patients with neuropathic low back-related leg pain consulting in UK primary care. Data from 511 patients were collected using standardised baseline clinical examinations (including magnetic resonance imaging scan findings), self-report questionnaires at baseline, 4 months, 12 months, and 3 years. Cases of possible neuropathic pain (NP) and persistent-NP were identified using either of 2 definitions: 1) clinical diagnosis of sciatica, 2) self-report version of leeds assessment for neurological symptoms and signs (s-LANSS). Mixed-effects models compared pain intensity (highest of mean leg or mean back pain [0-10 Numerical Rating Scale]) over 3-years between persistent-NP versus non-persistent-NP based on 1) clinical diagnosis, 2) s-LANSS. Logistic regression examined associations between potential prognostic factors and persistent-NP at 4 months based on the 2 NP definitions. At 4-months, using both definitions: 1) approximately 4 out of 10 patients had persistent-NP, 2) mean pain intensity was higher for patients with persistent-NP at all follow-up points compared to those without, 3) only pain self-efficacy was significantly associated with persistent-NP (s-LANSS: OR .98, sciatica: .98), but it did not predict cases of persistent-NP in either multivariable model. Based on factors routinely collected from self-report and clinical examination, it was not possible to predict persistent-NP in this population. PERSPECTIVE: This study provides evidence that neuropathic back-related leg pain in patients consulting in primary care is not always persistent. Patients with persistent neuropathic pain had worse outcomes than those without. Neither leg pain intensity, pain self-efficacy nor MRI scan findings predicted cases of persistent neuropathic pain in this patient population.

Estimating individualized treatment effects using a risk-modeling approach: an application to epidural steroid injections for lumbar spinal stenosis

ABSTRACT

Conventional "1-variable-at-a-time" analyses to identify treatment effect modifiers are often underpowered and prone to false-positive results. This study used a "risk-modeling" approach guided by the Predictive Approaches to Treatment effect Heterogeneity (PATH) Statement framework: (1) developing and validating a multivariable model to estimate predicted future back-related functional limitations as measured by the Roland-Morris Disability Questionnaire (RMDQ) and (2) stratifying patients from a randomized controlled trial (RCT) of lumbar epidural steroid injections (LESIs) for the treatment of lumbar spinal stenosis into subgroups with different individualized treatment effects on RMDQ scores at the 3-week follow-up. Model development and validation were conducted in a cohort (n = 3259) randomly split into training and testing sets in a 4:1 ratio. The model was developed in the testing set using linear regression with least absolute shrinkage and selection regularization and 5-fold cross-validation. The model was then applied in the testing set and subsequently in patients receiving the control treatment in the RCT of LESI. R2 values in the training set, testing set, and RCT were 0.38, 0.32, and 0.34, respectively. There was statistically significant modification ( P = 0.03) of the LESI treatment effect according to predicted risk quartile, with clinically relevant LESI treatment effect point estimates in the 2 quartiles with greatest predicted risk (-3.7 and -3.3 RMDQ points) and no effect in the lowest 2 quartiles. A multivariable risk-modeling approach identified subgroups of patients with lumbar spinal stenosis with a clinically relevant treatment effect of LESI on back-related functional limitations.

Sex differences in perceived expectations of the outcome of total hip and knee arthroplasties and their fulfillment: an observational cohort study

The influence of sex on preoperative expectations and their fulfillment following total hip and knee arthroplasty (THA/TKA) remains unexplored. We investigated differences between men and women in perceived preoperative expectations on the outcome of THA/TKA and their fulfillment 1 year postoperatively. We performed a cohort study. Expectations were collected preoperatively and 1 year postoperatively using the Hospital for Special Surgery Hip/Knee Replacement Expectations Surveys (HSS-HRES/KRES; not applicable = 0, applicable: back to normal = 1, much = 2/moderate = 3/slight improvement = 4). Fulfillment of expectations was calculated by subtracting preoperative from postoperative scores (score < 0:unfulfilled; score ≥ 0:fulfilled). We included patients with “applicable” expectations. Chi-square and ordinal regression were used to compare expectations and fulfillment regarding sex. 2333 THA (62% women) and 2398 TKA (65% women) patients were included. 77% of THA and 76% of TKA patients completed the HSS-HRES/HSS-KRES both preoperatively and 1 year postoperatively. Men more often perceived items as “applicable”, with differences in 9/20 (HSS-HRES) and 9/19 (HSS-KRES) preoperative items and, respectively, 12/20 (HSS-HRES) and 10/19 (HSS-KRES) postoperative items. The largest differences (> 10%) were found in sexual activity and working ability. 16/20 (HSS-HRES) and 14/19 (HSS-KRES) items showed an increased probability of having higher preoperative expectations of ≥ 10%, in favor of men. In all items, 60% of the respondents indicated that their expectation was fulfilled. Differences were observed in 16/20 (HSS-HRES) and 6/19 (HSS-KRES) items in favor of men. Sex differences were present in expectations and fulfillment, with higher applicability of items, preoperative expectations and fulfillment in men, especially on items related to functional activities.

Trial registration: Trial-ID NTR3348.

Intravenous Corticosteroid Therapy for Acute Lumbar Radicular Pain

Introduction: The efficacy of pharmacological interventions for acute lumbar radicular pain (ALRP) is limited, and systemic steroid use remains controversial. We evaluated the effectiveness and tolerance of systemic steroid use in a cohort of patients with ALRP. Methods: A retrospective cohort of 56 patients (including 24 females) were admitted with intractable ALRP resistance to conservative treatment of NSAIDs and opiates between the years 2016 and 2018. Medical records were studied for demographics, physical examination findings, Visual Analogue Score (VAS), IV steroids side effects, and recent imaging findings. All patients received a daily dose of IV 24 mg Dexamethasone until discharge, SNRB, or surgery. Results: The average IV steroid treatment was 3.9 (±2.8) days, with most patients showing significant pain relief allowing discharge (69.7%). SNRB was required in 19.6% and surgical intervention in 10.7% within the same admission. Multivariate analysis did not find any parameter to predict treatment failure (age, gender, motor/sensory deficit, CT/MRI findings). The motor deficit, positive straight leg raising (SLR), and dural sac compression on CT were higher in the intervention group but did not reach statistical significance. One patient required discontinuation of IV steroids due to elevated blood pressure. Conclusions: Despite the insufficient evidence in the literature, IV steroid treatment is still a viable option in ALRP treatment, with pain relief allowing discharge in 70% of patients and a low complication rate. Our study found daily 24 mg IV dexamethasone for ALRP to be an effective treatment and helpful in most patients admitted. This study supports the common practice used by spine units.

The Influence of Sex on Clinical Outcomes in Minimally Invasive Lumbar Decompression

BACKGROUND

Research focused on postoperative outcomes among men and women undergoing minimally invasive lumbar decompression (MIS LD) spine surgery is sparse. This study aims to assess the influence of sex on postoperative patient-reported outcome measure (PROM) evaluations and achievement of a minimum clinically important difference (MCID).

METHODS

A prospectively maintained surgical database was retrospectively queried for patients undergoing primary or revision, single or multilevel LD procedures from 2011 to 2019. Patients with incomplete visual analog scale (VAS) leg or back surveys were excluded. Demographic and operative variables were recorded, and a chi-squared analysis or t tests were used to compare by sex. PROMs were evaluated from preoperative to postoperative time points. PROM score differences and postoperative improvement were evaluated between sexes by a t test. Achievement of MCID by sex was compared using chi-squared analysis.

RESULTS

The study cohort (n = 572) was 70% male (n = 398), had an average age of 47 years, and 42% were obese. Sexes differed in preoperative VAS leg, Oswestry Disability Index (ODI), and 12-item short form (SF-12)-physical composite score (PCS) scores (all P < .05) and in ODI at 6 and 12 weeks (P = .048; P = .001) and VAS back and leg scores at 6 months (P = .039; P = .019). Both sexes significantly improved (P < .050) all PROMs at all time points except for VAS back at 1 year for women and ODI at 6 weeks and 6 months for men. The only significant difference in achievement of MCID was for ODI at 6 months (P = .008).

CONCLUSIONS

Significant preoperative differences were observed among sexes with ODI, SF-12-PCS, and VAS leg scores. By 1 year, there were no significant sex differences for any PROM or for achievement of MCID. MIS LD has an equivalent role for both sexes in achieving MCID.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

Results demonstrate no sex difference in PROMs following LD.

Gender differences in the surgical management of lumbar degenerative disease: a scoping review

OBJECTIVE

Despite efforts toward achieving gender equality in clinical trial enrollment, females are often underrepresented, and gender-specific data analysis is often unavailable. Identifying and reducing gender bias in medical decision-making and outcome reporting may facilitate equitable healthcare delivery. Gender disparity in the utilization of surgical therapy has been exemplified in the orthopedic literature through studies of total joint arthroplasty. A paucity of literature is available to guide the management of lumbar degenerative disease, which stratifies on the basis of demographic factors. The objective of this study was to systematically map and synthesize the adult surgical literature regarding gender differences in pre- and postoperative patient-reported clinical assessment scores for patients with lumbar degenerative disease (disc degeneration, disc herniation, spondylolisthesis, and spinal canal stenosis).

METHODS

A systematic scoping review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. MEDLINE, Embase, and the Cochrane Registry of Controlled Trials were searched from inception to September 2018. Study characteristics including patient demographics, diagnoses, procedures, and pre- and postoperative clinical assessment scores (pain, disability, and health-related quality of life [HRQoL]) were collected.

RESULTS

Thirty articles were identified, accounting for 32,951 patients. Six studies accounted for 84% of patients; 5 of the 6 studies were published by European groups. The most common lumbar degenerative conditions were disc herniation (59.0%), disc degeneration (20.3%), and spinal canal stenosis (15.9%). The majority of studies reported worse preoperative pain (93.3%), disability (81.3%), and HRQoL (75%) among females. The remainder reported equivalent preoperative scores between males and females. The majority of studies (63.3%) did not report preoperative duration of symptoms, and this represents a limitation of the data. Eighty percent of studies found that females had worse absolute postoperative scores in at least one outcome category (pain, disability, or HRQoL). The remainder reported equivalent absolute postoperative scores between males and females. Seventy-three percent of studies reported either an equivalent or greater interval change for females.

CONCLUSIONS

Female patients undergoing surgery for lumbar degenerative disease (disc degeneration, disc herniation, spondylolisthesis, and spinal canal stenosis) have worse absolute preoperative pain, disability, and HRQoL. Following surgery, females have worse absolute pain, disability, and HRQoL, but demonstrate an equal or greater interval change compared to males. Further studies should examine gender differences in preoperative workup and clinical course.

Efficacy and harms of orally, intramuscularly or intravenously administered glucocorticoids for sciatica: A systematic review and meta-analysis

BACKGROUND

Sciatica can be a debilitating condition and there is limited guidance on the use of glucocorticoids administered via the oral, intramuscular or intravenous route for this condition. These represent viable treatment options in the primary care setting.

OBJECTIVE

To evaluate the evidence on efficacy and harms of oral, IM and IV glucocorticoid administration for sciatica.

DATABASES AND DATA TREATMENT

MEDLINE, EMBASE, CENTRAL, CINAHL, PsycINFO (inception to October 2018) were searched for randomised placebo-controlled trials evaluating oral, IV or IM glucocorticoid administration for sciatica. Two authors extracted outcomes data. Continuous pain and disability outcomes were converted to a 0 (no pain/disability) to 100 (worst pain/disability) scale. Data were pooled using a random effects model. Overall quality of evidence was assessed using GRADE. Primary outcomes were leg pain and disability. Primary follow-up period was the immediate-term (<2 weeks from administration). We also considered adverse events.

RESULTS

Nine trials were eligible. One study [n = 27] provided low quality evidence of a small reduction in disability with early administration of oral prednisone (within 1 week); MD -13.4 [-23.3, -3.5] but not for pain MD -2.5 [-16.9, 11.9]. There was low quality evidence from one study [n = 78] of moderate reduction in disability and small reduction in pain with early (within 72 hr of symptom onset) single intramuscular administration of methylprednisolone acetate; MD -24.5 [-38.8, -10.2] and -14.0 [-27.4, -0.6], respectively. There were no immediate-term benefits with IV administration.

CONCLUSION

The effects of glucocorticoids on immediate-term leg pain or disability are uncertain. Future large high quality trials are needed to resolve this uncertainty.

Electrocatheter-mediated High-voltage Pulsed Radiofrequency of the Dorsal Root Ganglion in the Treatment of Chronic Lumbosacral Neuropathic Pain: A Randomized Controlled Study

OBJECTIVES

Despite the interest in scientific community, there is still poor evidence about pulsed radiofrequency (PRF) efficacy in the treatment of neuropathic pain. In order to determine whether high-voltage PRF and epidural adhesiolysis (PRF-EA) showed better results than epidural adhesiolysis alone (EA), a randomized, double-blind, comparative-effectiveness study was conducted in patients with chronic lumbosacral radiating pain and neuropathic features.

MATERIALS AND METHODS

A total of 41 patients were randomly allocated to 2 groups. Twenty-one patients were randomized to receive 2 cycles of 240 seconds high-voltage PRF followed by the injection of local anesthetics, hyaluronidase, and betamethasone, whereas 20 patients underwent sham stimulation followed by adhesiolysis. The treatment was delivered at the affected lumbosacral roots and patients, treating physicians and assessors were blinded to intervention.

RESULTS

A significant reduction of radiating pain was observed in mean Numeric Rating Scale score at follow-up. A change of -3.43 versus -1.75 (P=0.031) after 1 month and -3.34 versus -0.80 (P=0.005) after 6 months was reported in patients undergoing PRF-EA in comparison with EA, respectively. After 1 month, 57% of patients in the PRF-EA group experienced a pain reduction of ≥50% versus only 25% of patients allocated to EA (P=0.037). Improvement decreased to 48% in the PRF-EA group whereas only 10% of EA reported significant pain relief after 6 months (P=0.008).

DISCUSSION

High-voltage PRF of dorsal root ganglion delivered through multifunctional electrode provided significant pain relief and may be considered a valuable treatment in chronic lumbosacral radicular pain with neuropathic features.

Epidemiological Aspects of Low Back Pain

Low back pain (LBP) is a major health problem, particularly in the contemporary societies of highly developed countries. This study seeks to define the influence of basic demographic and social factors, such as gender, body mass, physical activity, and the type of work, on the occurrence of lumbosacral spine pain in the early and middle-late adulthood. The study was based on a self-reported survey, using the revised Oswestry Low Back Pain Disability Questionnaire to evaluate pain symptoms, and managing everyday tasks. Physical activity was evaluated on the Minnesota Leisure Time Physical Activity Questionnaire. We found that patients in the early adulthood had a significantly lower level of disability. The older patients had a greater low back pain and motion, sleeping, and social life problems. Neither did gender nor the type of work, leisure time physical activity, or body mass appreciably affect the level of disability due to low back pain in both younger and older patient groups. We conclude that, all else unchanged from the epidemiological standpoint, wear and tear of the spine structure naturally progressing with age seems a major determinant of the appearance of low back pain.

Association of Serum Serotonin and Pain in Patients with Chronic Low Back Pain before and after Spinal Surgery

Introduction

In this study we are aiming to evaluate the changes of serum serotonin and its association with pain in patients suffering from chronic low back pain before and after lumbar discectomy surgery.

Patients and Methods

A prospective study was performed on the patients referring to the outpatient clinic in Besat hospital, Hamadan University of Medical Sciences, Hamadan, Iran, during 2016. A 2 mL fasting blood sample was collected from each patient at preoperative day 1 and postoperative day 14 and they were measured for level of serum serotonin. Besides, all patients were asked for severity of their low back pain in preoperative day 1 and postoperative day 14 and scored their pain from zero to ten using a Numerical Rating Scale.

Results

Forty patients with the mean age of 47 ± 13 yrs/old (range 25–77) including 15 (37.5%) males were enrolled into the study. The overall mean score of preoperative pain was significantly decreased from 7.4 ± 2.18 (range 4–10) to the postoperative pain score 3.87 ± 2.92 (range 0–10) (P < .001). The overall levels of pre- and postoperative serum serotonin were 3.37 ± 1.27 (range 1.1–6.4) and 3.58 ± 1.32 (range .94–7.1) ng/mL, respectively, with no significant difference (P = .09). The levels of pre- and postoperative serum serotonin were significantly higher in males and patients older than 50 yrs/old compared to the females and patients younger than 50 yrs/old, respectively (P = .03 and .005, respectively). A significant inverse correlation between the postoperative levels of pain and serum serotonin was observed (r = -.36 and P = .02).

Conclusion

A negative medium strength linear relationship may exist between the postoperative serum serotonin and low back pain.

Predicting Likelihood of Surgery Before First Visit in Patients With Back and Lower Extremity Symptoms: A Simple Mathematical Model Based on More Than 8,000 Patients

STUDY DESIGN

Retrospective analysis of prospectively collected data.

OBJECTIVE

To create a data-driven triage system stratifying patients by likelihood of undergoing spinal surgery within 1 year of presentation.

SUMMARY OF BACKGROUND DATA

Low back pain (LBP) and radicular lower extremity (LE) symptoms are common musculoskeletal problems. There is currently no standard data-derived triage process based on information that can be obtained before the initial physician-patient encounter to direct patients to the optimal physician type.

METHODS

We analyzed patient-reported data from 8006 patients with a chief complaint of low back pain and/or LE radicular symptoms who presented to surgeons at a large multidisciplinary spine center between September 1, 2005 and June 30, 2016. Univariate and multivariate analysis identified independent risk factors for undergoing spinal surgery within 1 year of initial visit. A model incorporating these risk factors was created using a random sample of 80% of the total patients in our cohort, and validated on the remaining 20%.

RESULTS

The baseline 1-year surgery rate within our cohort was 39% for all patients and 42% for patients with LE symptoms. Those identified as high likelihood by the center's existing triage process had a surgery rate of 45%. The new triage scoring system proposed in this study was able to identify a high likelihood group in which 58% underwent surgery, which is a 46% higher surgery rate than in nontriaged patients and a 29% improvement from our institution's existing triage system.

CONCLUSION

The data-driven triage model and scoring system derived and validated in this study (Spine Surgery Likelihood-11), significantly improved existing processes in predicting the likelihood of undergoing spinal surgery within 1 year of initial presentation. This triage system will allow centers to more selectively screen for surgical candidates and more effectively direct patients to surgeons or nonoperative spine specialists.

LEVEL OF EVIDENCE

4.

Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group

BACKGROUND

Epidural corticosteroid injections are used frequently worldwide in the treatment of radicular pain. Concerns have arisen involving rare major neurologic injuries after this treatment. Recommendations to prevent these complications have been published, but local implementation is not always feasible due to local circumstances, necessitating local recommendations based on literature review.

METHODS

A work group of 4 stakeholder pain societies in Belgium, The Netherlands, and Luxembourg (Benelux) has reviewed the literature involving neurological complications after epidural corticosteroid injections and possible safety measures to prevent these major neurologic injuries.

RESULTS

Twenty-six considerations and recommendations were selected by the work group. These involve the use of imaging, injection equipment particulate and nonparticulate corticosteroids, epidural approach, and maximal volume to be injected.

CONCLUSION

Raising awareness about possible neurological complications and adoption of safety measures recommended by the work group aim at reducing the risks for these devastating events.

Gender differences in the relationship between workplace bullying and subjective back and neck pain: A two-wave study in a Norwegian probability sample

OBJECTIVE

The association between exposure to bullying at work and subsequent pain reports is relatively well-established, but few studies have examined possible moderators of this relationship. As gender is a known risk factor for pain, with women reporting pain levels of higher intensity and longer duration, a possible gender difference in the relationship between bullying and pain has been suggested, but not sufficiently tested. The objective of the present study was therefore to examine whether gender moderates the prospective relationship between exposure to workplace bullying behaviours and subsequent subjective back and neck pain.

METHODS

A national probability sample of Norwegian workers (N=1003) was collected at two time points with a six-month time-lag. Assumptions were tested using regression and moderation analyses.

RESULTS

Exposure to bullying behaviours was associated with increased reports of subjective back and neck pain over time, and this relationship was moderated by gender. However, the interaction took a different form than expected, with back and neck pain increasing in response to bullying among men only, to a degree that nullified the baseline gender difference.

CONCLUSION

The assumption that being female is a vulnerability factor for the development of pain in the aftermath of psychosocial stressors such as bullying was contradicted in the present study. Instead, women's relatively high baseline pain levels remain stable over time even after exposure to workplace bullying, while men's relatively low baseline pain levels increase in response to bullying, ultimately becoming tangent to the pain reported by women.

Prognostic Factors for Persistent Leg-Pain in Patients Hospitalized With Acute Sciatica

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To identify potential prognostic factors for persistent leg-pain at 12 months among patients hospitalized with acute severe sciatica.

SUMMARY OF BACKGROUND DATA

The long-term outcome for patients admitted to hospital with sciatica is generally unfavorable. Results concerning prognostic factors for persistent sciatica are limited and conflicting.

METHODS

A total of 210 patients acutely admitted to hospital for either surgical or nonsurgical treatment of sciatica were consecutively recruited and received a thorough clinical and radiographic examination in addition to responding to a comprehensive questionnaire. Follow-up assessments were done at 6 weeks, 6 months, and 12 months. Potential prognostic factors were measured at baseline and at 6 weeks. The impact of these factors on leg-pain was analyzed by multiple linear regression modeling.

RESULTS

A total of 151 patients completed the entire study, 93 receiving nonrandomized surgical treatment. The final multivariate models showed that the following factors were significantly associated with leg-pain at 12 months: high psychosocial risk according to the Örebro Musculosceletal Pain Questionnaire (unstandardized beta coefficient 1.55, 95% confidence interval [CI] 0.72-2.38, P < 0.001), not receiving surgical treatment (1.11, 95% CI 0.29-1.93, P = 0.01), not actively employed upon admission (1.47, 95% CI 0.63-2.31, P < 0.01), and self-reported leg-pain recorded 6 weeks posthospital admission (0.49, 95% CI 0.34-0.63, P < 0.001). Interaction analysis showed that the Örebro Musculosceletal Pain Questionnaire had significant prognostic value only on the nonsurgically treated patients (3.26, 95% CI 1.89-4.63, P < 0.001).

CONCLUSION

The results suggest that a psychosocial screening tool and the implementation of a 6-week postadmission follow-up has prognostic value in the hospital management of severe sciatica.

LEVEL OF EVIDENCE

2.

A systematic review of preoperative predictors for postoperative clinical outcomes following lumbar discectomy

BACKGROUND CONTEXT

Sciatica is often caused by a herniated lumbar intervertebral disc. When conservative treatment fails, a lumbar discectomy can be performed. Surgical treatment via lumbar discectomy is not always successful and may depend on a variety of preoperative factors. It remains unclear which, if any, preoperative factors can predict postsurgical clinical outcomes.

PURPOSE

This review aimed to determine preoperative predictors that are associated with postsurgical clinical outcomes in patients undergoing lumbar discectomy.

STUDY DESIGN

This is a systematic review.

METHODS

This systematic review of the scientific literature followed the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. MEDLINE and PubMed were systematically searched through June 2014. Results were screened for relevance independently, and full-text studies were assessed for eligibility. Reporting quality was assessed using a modified Newcastle-Ottawa Scale. Quality of evidence was assessed using a modified version of Sackett's Criteria of Evidence Support. No financial support was provided for this study. No potential conflict of interest-associated biases were present from any of the authors.

RESULTS

The search strategy yielded 1,147 studies, of which a total of 40 high-quality studies were included. There were 17 positive predictors, 20 negative predictors, 43 non-significant predictors, and 15 conflicting predictors determined. Preoperative predictors associated with positive postoperative outcomes included more severe leg pain, better mental health status, shorter duration of symptoms, and younger age. Preoperative predictors associated with negative postoperative outcomes included intact annulus fibrosus, longer duration of sick leave, worker's compensation, and greater severity of baseline symptoms. Several preoperative factors including motor deficit, side and level of herniation, presence of type 1 Modic changes and degeneration, age, and gender had non-significant associations with postoperative clinical outcomes.

CONCLUSIONS

It may be possible for certain preoperative factors to be targeted for clinical evaluation by spine surgeons to assess the suitability of patients for lumbar discectomy surgery, the hope being to thereby improve postoperative clinical outcomes. Prospective cohort studies are required to increase the level of evidence with regard to significant predictive factors.

Inferior Outcome of Lumbar Disc Surgery in Women Due to Inferior Preoperative Status: A Prospective Study in 11,237 Patients

STUDY DESIGN

Analysis of prospectively collected data in a national register.

OBJECTIVE

The aim of this study was to, in a nationwide perspective, evaluate whether there exist sex differences in outcome of lumbar disc herniation (LDH) surgery and whether the gender-specific referral pattern influence the outcome.

SUMMARY OF BACKGROUND DATA

Previous studies infer that women are referred to LDH surgery with inferior clinical status than men. Whether the surgical outcome is different in men and women is debated.

METHODS

We found in the validated Swedish National Spine Surgical Register, 11,237 patients aged 13 to 89 years who between years 2000 and 2010 were registered in SweSpine with LDH surgery and with both preoperative and 1 year postoperative data. The register includes data on sex, age, smoking habits, walking distance, consumption of analgesics, back and leg pain (Visual Analogue Scale; VAS), quality of life (EuroQol; EQ5D and Short Form-36 Questionnaire; SF-36), and disability (Oswestry Disability Index; ODI). We evaluated sex discrepancies in response to surgery and 1 year postoperative outcome.

RESULTS

All end point variables improved markedly with a similar rate in both men and women (all P < 0.001). As women preoperatively reported higher consumption of analgesics, more impaired walking distance, more back and leg pain, inferior quality of life and higher disability than men (all P < 0.001) and improvement by surgery was similar in both sex, women reported 1 year after surgery still higher consumption of analgesics, more impaired walking distance, more back and leg pain, inferior quality of life, and higher disability (all P < 0.001).

CONCLUSION

Surgery for LDH confers great improvements in both sex. Because women are scheduled for surgery with an inferior clinical status than men and the improvement is similar in both sex, the 1 year postoperative outcome is inferior in women than in men.

LEVEL OF EVIDENCE

2.

Gender differences in the surgical treatment of lumbar disc herniation in elderly

PURPOSE

Outcome after lumbar disc herniation (LDH) surgery in middle-aged patient is usually reported to fulfill the criteria for successful outcome. It is also known that women in these years have an inferior outcome compared to men. This study evaluates whether the same gender differences exist in elderly.

METHOD

In the national Swedish register for spine surgery (SweSpine) we identified 1668 patients ≥65 years. 1250 of these patients had both pre- and 1-year postoperative data registered, 53 % males with mean age 70.6 ± 5.0 (mean ± SD) and 47 % females with mean age 71.3 ± 5.2. All were surgically treated due to LDH between 2000 and 2012.

RESULTS

Before surgery both men and women had severe impairment, compared to normative data, in all patient-reported outcome measures (PROMs), with women having inferior status to men. Improvement by surgery was similar in both genders but neither of them reached normative values in quality of life as compared to normative age-matched individuals. As a consequence of this women 1 year after surgery had more back and leg pain, higher consumption of analgesics, greater impairment in walking distance and inferior scoring in virtually all registered PROMs compared to men (all p < 0.005). In spite of this women were as satisfied with the surgical outcome as the men.

CONCLUSION

Elderly women with LDH surgery report inferior outcome compared to males, mainly as a result of being referred to surgery with an inferior status but are despite this as satisfied with outcome as the men.

Prognostic value of magnetic resonance imaging findings in patients with sciatica

OBJECTIVE This study aimed to determine the prognostic value of MRI variables to predict outcome in patients with herniated disc-related sciatica, and whether MRI could facilitate the decision making between early surgery and prolonged conservative care in these patients. METHODS A prospective observational evaluation of patients enrolled in a randomized trial with 1-year follow-up was completed. A total of 283 patients with sciatica who had a radiologically confirmed disc herniation were randomized either to surgery or to prolonged conservative care with surgery if needed. Outcome measures were recovery and leg pain severity. Recovery was registered on a 7-point Likert scale. Complete/near complete recovery was considered a satisfactory outcome. Leg pain severity was measured on a 0- to 100-mm visual analog scale. Multiple MRI characteristics of the degenerated disc herniation were independently scored by 3 spine experts. Cox models were used to study the influence of MRI variables on rate of recovery, and linear mixed models were used to determine the predictive value of MRI variables for leg pain severity during follow-up. The interaction of each MRI predictor with treatment allocation was tested. There were no study-specific conflicts of interest. RESULTS Baseline MRI variables associated with less leg pain severity were the reader's assessment of presence of nerve root compression (p < 0.001), and assessment of extrusion compared with protrusion of the disc herniation (p = 0.006). Both variables tended to be associated, but not significantly, with satisfactory outcome during follow-up (HR 1.45, 95% CI 0.93-2.24, and HR 1.24, 95% CI 0.96-1.61, respectively). The size of disc herniation at baseline was not associated with outcome. There was no significant change in the effects between treatment groups. CONCLUSIONS MRI assessment of the presence of nerve root compression and extrusion of a herniated disc at baseline was associated with less leg pain during 1-year follow-up, irrespective of a surgical or conservative treatment. MRI findings seem not to be helpful in determining which patients might fare better with early surgery compared with a strategy of prolonged conservative care. Clinical trial registration no.: ISRCTN26872154 ( controlled-trials.com ).

Predictive Factors for Successful Outcome of Pulsed Radiofrequency Treatment in Patients with Intractable Lumbosacral Radicular Pain

BACKGROUND

In a previous prospective study on pulsed radiofrequency (PRF) treatment adjacent to the lumbar dorsal root ganglion (DRG) for patients with chronic lumbosacral radicular pain, we reported success in 55.4% of the patients at 6 months. Identification of predictors for success after PRF may improve outcome. We assessed the predictors of PRF in patients with chronic intractable lumbosacral radicular pain.

METHODS

Patients with monosegmental chronic lumbosacral radicular pain of L5 or S1 first received a selective nerve root block at the corresponding level. Independent of the result of this block a PRF treatment at the same level was performed. At 6 weeks, 3 months, and 6 months after the procedure the outcome was evaluated.

RESULTS

A positive diagnostic nerve root block and age ≥ 55 were predictive factors for successful outcome at 6 months, while disability was a negative predictor.The use of failed back surgery syndrome, gender, duration of pain, Numerical Rating Scale, level and side of treatment, DN4, and RAND-36 as predictors for success was not supported.

CONCLUSIONS

Successful outcome after PRF adjacent to the DRG, in patients with intractable chronic lumbosacral radicular pain, is more likely in patients ≥ 55 years, with limited disability and after a positive diagnostic nerve root block. A combination of all these factors creates a fair predictive value (AUC: 0.73).

The Effect of Smoking on the Risk of Sciatica: A Meta-analysis

BACKGROUND

The role of smoking in sciatica is unknown. This study aimed to estimate the effect of smoking on lumbar radicular pain and clinically verified sciatica.

METHODS

Comprehensive literature searches were conducted in PubMed, Embase, Web of Science, Scopus, Google Scholar, and ResearchGate databases from 1964 through March 2015. We used a random-effects meta-analysis, assessed heterogeneity and publication bias, and performed sensitivity analyses with regard to study design, methodological quality of included studies, and publication bias.

RESULTS

Twenty-eight (7 cross-sectional [n = 20,111 participants], 8 case control [n = 10,815], and 13 cohort [n = 443,199]) studies qualified for a meta-analysis. Current smokers had an increased risk of lumbar radicular pain or clinically verified sciatica (pooled adjusted odds ratio [OR] 1.46; 95% confidence interval [CI], 1.30-1.64, n = 459,023). Former smokers had only slightly elevated risk compared with never smokers (pooled adjusted OR 1.15; 95% CI, 1.02-1.30, n = 387,196). For current smoking the pooled adjusted OR was 1.64 (95% CI, 1.24-2.16, n = 10,853) for lumbar radicular pain, 1.35 (95% CI, 1.09-1.68, n = 110,374) for clinically verified sciatica, and 1.45 (95% CI, 1.16-1.80, n = 337,796) for hospitalization or surgery due to a herniated lumbar disc or sciatica. The corresponding estimates for past smoking were 1.57 (95% CI, 0.98-2.52), 1.09 (95% CI, 1.00-1.19), and 1.10 (95% CI, 0.96-1.26). The associations did not differ between men and women, and they were independent of study design. Moreover, there was no evidence of publication bias, and the observed associations were not due to selection or detection bias, or confounding factors.

CONCLUSIONS

Smoking is a modest risk factor for lumbar radicular pain and clinically verified sciatica. Smoking cessation appears to reduce, but not entirely eliminate, the excess risk.

Influence of gender on patient-oriented outcomes in spine surgery

PURPOSE

Few studies have examined gender differences in patient-oriented health-related quality of life before and after spine surgery. This study examined the influence of gender on baseline status and 1-year postoperative outcomes in a large series of patients undergoing surgery for different degenerative spinal disorders.

METHODS

The study included 1518 patients [812 men and 706 women; mean (SD) age 61.4 ± 16.2 years], with three different pathologies (disc herniation, degenerative spondylolisthesis, or spinal stenosis), treated with specified surgical approaches. Preoperatively and 12 months postoperatively, patients completed the multidimensional Core Outcome Measures Index (COMI). Medical history, surgical details and perioperative complications were documented with the Eurospine "Spine Tango" Surgery 2006 form.

RESULTS

Preoperatively and for all three pathologies, women had significantly (p < 0.05) worse COMI-scores than men, especially for the sub-domains "leg/buttock pain", "dominant pain intensity", and "general quality of life"; the change in the COMI sum score 12 months postoperatively showed no significant gender differences for any pathology (p > 0.05). 71.3 % males and 72.9 % females achieved the minimal clinically important change score (MCIC; 2.2 point reduction) for the COMI. Controlling for potential cofounders (preoperative COMI, ASA, complications, pathology), gender showed no significant association with the failure to achieve MCIC.

CONCLUSIONS

This results show that women do not differ significantly from men regarding their postoperative outcome, even though they present with a worse preoperative status. The management of a patient's condition should not differ depending on their gender, since both men and women are able to improve to a similar extent.

Gender differences in patients scheduled for lumbar disc herniation surgery: a National Register Study including 15,631 operations

PURPOSE

Previous studies have shown gender differences in preoperative status and outcome of spine surgery. This study explores whether gender differences in preoperative demographics exist in patients scheduled for lumbar disc herniation (LDH) surgery.

METHODS

This study includes the preoperative data of the 15,631 patients operated for LDH between years 2000 and 2010, registered in the national Swedish spine register (SweSpine). We analysed preoperative gender differences in age, smoking habits, walking distance, consumption of analgesics, back and leg pain (Visual Analogue Scale; VAS), quality of life (EuroQol; EQ 5D and Short Form-36 Questionnaire; SF-36) and disability (Oswestry Disability Index; ODI).

RESULTS

44 % of the patients were women (mean age 45 ± 13) and 56 % men (mean age 44 ± 13). More women than men were smokers (26 versus 21 %, p < 0.001). Women also reported inferior walking ability (less than 100 metre walking ability 37 vs 30 %; p < 0.001), consumed more analgesics (92 versus 84 %; p < 0.001), reported higher level of pain (mean difference VAS leg 6 (95 % CI 5-7)), had inferior health-related quality of life (mean difference EQ 5D 0.07 (95 % CI 0.05-0.08)) and had higher disability (mean difference ODI 6 (95 % CI 5-6)).

CONCLUSIONS

Women scheduled for LDH surgery report inferior clinical status than men scheduled for the same operation. We have in the literature found no evidence-based data that support such a difference, and the reason for the discrepancy is unclear.

Nonoperative treatment for lumbosacral radiculopathy: what factors predict treatment failure?

BACKGROUND

Prior studies of nonoperative treatment for lumbosacral radiculopathy have identified potential predictors of treatment failure, defined by persistent pain, persistent disability, lack of recovery, or subsequent surgery. However, few predictors have been replicated, with the exception of higher leg pain intensity, as a predictor of subsequent surgery.

QUESTIONS/PURPOSES

We asked two research questions: (1) Does higher baseline leg pain intensity predict subsequent lumbar surgery? (2) Can other previously identified "candidate" predictors of nonoperative treatment failure be replicated?

METHODS

Between January 2008 and March 2009, 154 participants with acute lumbosacral radicular pain were enrolled in a prospective database; 128 participants (83%) received nonoperative treatment and 26 (17%) received surgery over 2-year followup. Ninety-four nonoperative participants (73%) responded to followup questionnaires. We examined associations between previously identified "candidate" predictors and treatment failure defined as (1) subsequent surgery; (2) persistent leg pain on a visual analog scale; (3) persistent disability on the Oswestry Disability Index; or (4) participant-reported lack of recovery over 2-year followup. Confounding variables including sociodemographics, clinical factors, and imaging characteristics were evaluated using an exploratory bivariate analysis followed by a multivariate analysis.

RESULTS

With the numbers available, higher baseline leg pain intensity was not an independent predictor of subsequent surgery (adjusted odds ratio [aOR], 1.22 per point of baseline leg pain; 95% confidence interval [CI], 0.98-1.53; p = 0.08). Prior low back pain (aOR, 4.79; 95% CI, 1.01-22.7; p = 0.05) and a positive straight leg raise test (aOR, 4.38; 95% CI, 1.60-11.9; p = 0.004) predicted subsequent surgery. Workers compensation claims predicted persistent leg pain (aOR, 9.04; 95% CI, 1.01-81; p = 0.05) and disability (aOR, 5.99; 95% CI, 1.09-32.7; p = 0.04). Female sex predicted persistent disability (aOR, 3.16; 95% CI, 1.03-9.69; p = 0.05) and perceived lack of recovery (aOR, 2.44; 95% CI, 1.02-5.84; p = 0.05).

CONCLUSIONS

Higher baseline leg pain intensity was not confirmed as a predictor of subsequent surgery. However, the directionality of the association seen was consistent with prior reports, suggesting Type II error as a possible explanation; larger studies are needed to further examine this relationship. Clinicians should be aware of potential factors that may predict nonoperative treatment failure, including prior low back pain or a positive straight leg raise test as predictors of subsequent surgery, workers compensation claims as predictors of persistent leg pain and disability, and female sex as a predictor of persistent disability and lack of recovery.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Evaluation of transforaminal endoscopic lumbar discectomy in the treatment of lumbar disc herniation

PURPOSE

The purpose of this study was to evaluate the efficacy of transforaminal endoscopic lumbar discectomy (TELD) in the treatment of lumbar disc herniation (LDH) and to identify the relationship between TELD efficacy and age.

METHODS

A total of 207 consecutive LDH patients who had undergone TELD with the THESSYS system from January 2013 to September 2014 were divided into two groups on the basis of their age, with 108 cases in the ≤ 45-year-old age group and 99 cases in the >45-year-old group. The Oswestry Disability Index (ODI) was used to quantify the pain relief. The degree of pain and disability were measured on the basis of the visual analog scale (VAS) and the modified MacNab criteria. Complications, duration of hospital stay, surgical costs, and operation time were recorded and compared between the two groups. Spearman's coefficient of rank correlation was used to assess the learning curves for TELD.

RESULTS

The mean pre-operative and postoperative VAS and ODI scores significantly improved in both age ≤ 45 group and age >45 group, with no significant differences between them. In age ≤45 group, 56 % had excellent outcomes, 28 % good, 14 % fair, and 3 % poor. In the age >45 group, 51 % had excellent outcomes, 20 % good, 25 % fair, and 4 % poor. The average lengths of hospital stay for the age ≤ 45 group and age >45 group were 6.8 and 8.4 days, respectively. The mean time to return to work or normal activities was ten days for the age ≤ 45 group and 15 days for the age >45 group. The mean operative time for the age ≤ 45 group was 94 minutes and that for age >45 group was 97 minutes. The surgical cost of age ≤ 45 group was 15,480 RMB, which was lower than the 16,381 RMB of age >45 group. A total of 14 patients in the age ≤ 45 group and 13 patients in age >45 group used analgesic medications. Three and five recurrences were reported in the age ≤ 45 group and age >45, respectively. The steep learning curves of operative time plotted against the number of surgeries conducted suggest that the TELD technique can be mastered quickly in terms of reducing the duration of operation.

CONCLUSIONS

The efficacy of TELD is relatively good for the selected young and elderly patients in this study. Therefore, age is not a predictor of TELD surgery-related outcomes.

Predictors of clinical outcome following lumbar disc surgery: the value of historical, physical examination, and muscle function variables

PURPOSE

Explore the relationships between preoperative findings and clinical outcome following lumbar disc surgery, and investigate the prognostic value of physical examination findings after accounting for information acquired from the clinical history.

METHODS

We recruited 55 adult patients scheduled for first time, single-level lumbar discectomy. Participants underwent a standardized preoperative evaluation including real-time ultrasound imaging assessment of lumbar multifidus function, and an 8-week postoperative rehabilitation programme. Clinical outcome was defined by change in disability, and leg and low back pain (LBP) intensity at 10 weeks. Linear regression models were used to identify univariate and multivariate predictors of outcome.

RESULTS

Univariate predictors of better outcome varied depending on the outcome measure. Clinical history predictors included a greater proportion of leg pain to LBP, pain medication use, greater time to surgery, and no history of previous physical or injection therapy. Physical examination predictors were a positive straight or cross straight leg raise test, diminished lower extremity strength, sensation or reflexes, and the presence of postural abnormality or pain peripheralization. Preoperative pain peripheralization remained a significant predictor of improved disability (p = 0.04) and LBP (p = 0.02) after accounting for information from the clinical history. Preoperative lumbar multifidus function was not associated with clinical outcome.

CONCLUSIONS

Information gleaned from the clinical history and physical examination helps to identify patients more likely to succeed with lumbar disc surgery. While this study helps to inform clinical practice, additional research confirming these results is required prior to confident clinical implementation.

Outcome prediction in chronic unilateral lumbar radiculopathy: prospective cohort study

Background

Identification of prognostic factors for persistent pain and disability are important for better understanding of the clinical course of chronic unilateral lumbar radiculopathy and to assist clinical decision-making. There is a lack of scientific evidence concerning prognostic factors. The aim of this study was to identify clinically relevant predictors for outcome at 52 weeks.

Methods

116 patients were included in a sham controlled clinical trial on epidural injection of glucocorticoids in patients with chronic unilateral lumbar radiculopathy. Success at follow-up was ≤17.5 for visual analogue scale (VAS) leg pain, ≤22.5 for VAS back pain and ≤20 for Oswestry Disability Index (ODI). Fifteen clinically relevant variables included demographic, psychosocial, clinical and radiological data and were analysed using a logistic multivariable regression analysis.

Results

At follow-up, 75 (64.7%) patients had reached a successful outcome with an ODI score ≤20, 54 (46.6%) with a VAS leg pain score ≤17.5, and 47 (40.5%) with a VAS back pain score ≤22.5.

Lower age (OR 0.94 (CI 0.89–0.99) for each year decrease in age) and FABQ Work ≥34 (OR 0.16 (CI 0.04-0.61)) were independent variables predicting a successful outcome on the ODI.

Higher education (OR 5.77 (CI 1.46–22.87)) and working full-time (OR 2.70 (CI 1.02–7.18)) were statistically significant (P <0.05) independent predictors for successful outcome (VAS score ≤17.5) on the measure of leg pain. Lower age predicted success on ODI (OR 0.94 (95% CI 0.89 to 0.99) for each year) and less back pain (OR 0.94 (0.90 to 0.99)), while higher education (OR 5.77 (1.46 to 22.87)), working full-time (OR 2.70 (1.02 to 7.18)) and muscle weakness at baseline (OR 4.11 (1.24 to 13.61) predicted less leg pain, and reflex impairment at baseline predicted the contrary (OR 0.39 (0.15 to 0.97)).

Conclusions

Lower age, higher education, working full-time and low fear avoidance beliefs each predict a better outcome of chronic unilateral lumbar radiculopathy. Specifically, lower age and low fear avoidance predict a better functional outcome and less back pain, while higher education and working full-time predict less leg pain. These results should be validated in further studies before being used to inform patients.

Trial registration

Current Controlled Trials ISRCTN12574253. Registered 18 May 2005.

Pulsed radiofrequency for chronic intractable lumbosacral radicular pain: a six-month cohort study

BACKGROUND AND OBJECTIVES

There is little evidence concerning the medical management of lumbosacral radicular pain. The prognosis for patients suffering pain for more than 3 months is poor. Pulsed radiofrequency (PRF) treatment of the dorsal root ganglion (DRG) has been suggested as a minimally invasive treatment. We studied the effect on pain and quality of life of PRF treatment of the DRG in patients with chronic, severe lumbosacral radicular pain.

METHODS

Patients with lumbosacral radicular pain were screened to select a homogeneous population. PRF treatment of the DRG was performed at L5 or S1. Evaluation was carried out at 6 weeks, 3 months, and 6 months. Pain reduction and "fully recovered" or "much improvement," in terms of the global perceived effect, were the primary outcomes. Quality of life (RAND-36), disability (Oswestry Disability Index), and the neuropathic pain scales leeds assessment of neuropathic symptoms and signs (LANSS) and DN4 were registered at each time point. Medication use was scored with the Medication Quantification Scale.

RESULTS

Out of 461 screened patients, 65 were included. According to the intention to treat analysis, clinical success was achieved in 56.9%, 52.3%, and 55.4% of the patients at respectively 6 weeks, 3 months, and 6 months. DN4, Oswestry Disability Index and physical component for the RAND-36 quality of life improved significantly while the mental component remained unchanged. The number of patients on opioids was reduced.

CONCLUSIONS

PRF treatment of the DRG may be considered for patients with chronic, severe lumbosacral radicular pain refractory to conventional medical management.

Lumbar disk herniation surgery: outcome and predictors

Study Design A retrospective cohort study. Objectives To determine the outcome and any differences in the clinical results of three different surgical methods for lumbar disk herniation and to assess the effect of factors that could predict the outcome of surgery. Methods We evaluated 148 patients who had operations for lumbar disk herniation from March 2006 to March 2011 using three different surgical techniques (laminectomy, microscopically assisted percutaneous nucleotomy, and spinous process osteotomy) by using Japanese Orthopaedic Association (JOA) Back Pain Evaluation Questionnaire, Resumption of Activities of Daily Living scale and changes of visual analog scale (VAS) for low back pain and radicular pain. Our study questionnaire addressed patient subjective satisfaction with the operation, residual complaints, and job resumption. Data were analyzed with SPSS version 16.0 (SPSS, Inc., Chicago, Illinois, United States). Statistical significance was set at 0.05. For statistical analysis, chi-square test, Mann-Whitney U test, Kruskal-Wallis test, and repeated measure analysis were performed. For determining the confounding factors, univariate analysis by chi-square test was used and followed by logistic regression analysis. Results Ninety-four percent of our patients were satisfied with the results of their surgeries. VAS documented an overall 93.3% success rate for reduction of radicular pain. Laminectomy resulted in better outcome in terms of JOA Back Pain Evaluation Questionnaire. The outcome of surgery did not significantly differ by age, sex, level of education, preoperative VAS for back, preoperative VAS for radicular pain, return to previous job, or level of herniation. Conclusion Surgery for lumbar disk herniation is effective in reducing radicular pain (93.4%). All three surgical approaches resulted in significant decrease in preoperative radicular pain and low back pain, but intergroup variation in the outcome was not achieved. As indicated by JOA Back Pain Evaluation Questionnaire-Low Back Pain (JOABPQ-LBP) and lumbar function functional scores, laminectomy achieved significantly better outcome compared with other methods. It is worth mentioning that relief of radicular pain was associated with subjective satisfaction with the surgery among our study population. Predictive factors for ineffective surgical treatment for lumbar disk herniation were female sex and negative preoperative straight leg raising. Age, level of education, and preoperative VAS for low back pain were other factors that showed prediction power.

Reliability of gadolinium-enhanced magnetic resonance imaging findings and their correlation with clinical outcome in patients with sciatica

BACKGROUND CONTEXT

Gadolinium-enhanced magnetic resonance imaging (Gd-MRI) is often performed in the evaluation of patients with persistent sciatica after lumbar disc surgery. However, correlation between enhancement and clinical findings is debated, and limited data are available regarding the reliability of enhancement findings.

PURPOSE

To evaluate the reliability of Gd-MRI findings and their correlation with clinical findings in patients with sciatica.

STUDY DESIGN

Prospective observational evaluation of patients who were enrolled in a randomized trial with 1-year follow-up.

PATIENTS SAMPLE

Patients with 6- to 12-week sciatica, who participated in a multicentre randomized clinical trial comparing an early surgery strategy with prolonged conservative care with surgery if needed. In total 204 patients underwent Gd-MRI at baseline and after 1 year.

OUTCOME MEASURES

Patients were assessed by means of the Roland Disability Questionnaire (RDQ) for sciatica, visual analog scale (VAS) for leg pain, and patient-reported perceived recovery at 1 year. Kappa coefficients were used to assess interobserver reliability.

METHODS

In total, 204 patients underwent Gd-MRI at baseline and after 1 year. Magnetic resonance imaging findings were correlated to the outcome measures using the Mann-Whitney U test for continuous data and Fisher exact tests for categorical data.

RESULTS

Poor-to-moderate agreement was observed regarding Gd enhancement of the herniated disc and compressed nerve root (kappa<0.41), which was in contrast with excellent interobserver agreement of the disc level of the herniated disc and compressed nerve root (kappa>0.95). Of the 59 patients with an enhancing herniated disc at 1 year, 86% reported recovery compared with 100% of the 12 patients with nonenhancing herniated discs (p=.34). Of the 12 patients with enhancement of the most affected nerve root at 1 year, 83% reported recovery compared with 85% of the 192 patients with no enhancement (p=.69). Patients with and without enhancing herniated discs or nerve roots at 1 year reported comparable outcomes on RDQ and VAS-leg pain.

CONCLUSIONS

Reliability of Gd-MRI findings was poor-to-moderate and no correlation was observed between enhancement and clinical findings at 1-year follow-up.

Obesity as a risk factor for sciatica: a meta-analysis

The aim of this study was to assess the associations of overweight and obesity with lumbar radicular pain and sciatica using a meta-analysis. We searched the PubMed, Embase, Scopus, and Web of Science databases from 1966 to July 2013. We performed a random-effects meta-analysis and assessed publication bias. We included 26 (8 cross-sectional, 7 case-control, and 11 cohort) studies. Both overweight (pooled odds ratio (OR) = 1.23, 95% confidence interval (CI): 1.14, 1.33; n = 19,165) and obesity (OR = 1.40, 95% CI: 1.27, 1.55; n = 19,165) were associated with lumbar radicular pain. The pooled odds ratio for physician-diagnosed sciatica was 1.12 (95% CI: 1.04, 1.20; n = 109,724) for overweight and 1.31 (95% CI: 1.07, 1.62; n = 115,661) for obesity. Overweight (OR = 1.16, 95% CI: 1.09, 1.24; n = 358,328) and obesity (OR = 1.38, 95% CI: 1.23, 1.54; n = 358,328) were associated with increased risk of hospitalization for sciatica, and overweight/obesity was associated with increased risk of surgery for lumbar disc herniation (OR = 1.89, 95% CI: 1.25, 2.86; n = 73,982). Associations were similar for men and women and were independent of the design and quality of included studies. There was no evidence of publication bias. Our findings consistently showed that both overweight and obesity are risk factors for lumbar radicular pain and sciatica in men and women, with a dose-response relationship.

Influence of low back pain and prognostic value of MRI in sciatica patients in relation to back pain

BACKGROUND

Patients with sciatica frequently complain about associated back pain. It is not known whether there are prognostic relevant differences in Magnetic Resonance Imaging (MRI) findings between sciatica patients with and without disabling back pain.

METHODS

The study population contained patients with sciatica who underwent a baseline MRI to assess eligibility for a randomized trial designed to compare the efficacy of early surgery with prolonged conservative care for sciatica. Two neuroradiologists and one neurosurgeon independently evaluated all MR images. The MRI readers were blinded to symptom status. The MRI findings were compared between sciatica patients with and without disabling back pain. The presence of disabling back pain at baseline was correlated with perceived recovery at one year.

RESULTS

Of 379 included sciatica patients, 158 (42%) had disabling back pain. Of the patients with both sciatica and disabling back pain 68% did reveal a herniated disc with nerve root compression on MRI, compared to 88% of patients with predominantly sciatica (P<0.001). The existence of disabling back pain in sciatica at baseline was negatively associated with perceived recovery at one year (Odds ratio [OR] 0.32, 95% Confidence Interval 0.18-0.56, P<0.001). Sciatica patients with disabling back pain in absence of nerve root compression on MRI at baseline reported less perceived recovery at one year compared to those with predominantly sciatica and nerve root compression on MRI (50% vs 91%, P<0.001).

CONCLUSION

Sciatica patients with disabling low back pain reported an unfavorable outcome at one-year follow-up compared to those with predominantly sciatica. If additionally a clear herniated disc with nerve root compression on MRI was absent, the results were even worse.

An overview of predictors for persistent neuropathic pain

Neuropathic pain (NP) is a pain arising as a direct consequence of a lesion or disease affecting the somatosensory system. A variety of factors associated with the development of persistent NP have been suggested. The goal of the present article is to provide an overview of current knowledge about prognostic factors for persistent NP. The International Classification of Functioning, Disability and Health model is used as a framework to categorize these predictors. Most reported predictors in the literature were found in the International Classification of Functioning, Disability and Health-category of personal factors, especially age and psychological factors, functions and structure, including sensory signs and symptoms. Predictors in the category of environmental factors, activities and participation were less frequently described.

Surgery versus prolonged conservative treatment for sciatica: 5-year results of a randomised controlled trial

OBJECTIVE

This study describes the 5 years' results of the Sciatica trial focused on pain, disability, (un)satisfactory recovery and predictors for unsatisfactory recovery.

DESIGN

A randomised controlled trial.

SETTING

Nine Dutch hospitals.

PARTICIPANTS

Five years' follow-up data from 231 of 283 patients (82%) were collected.

INTERVENTION

Early surgery or an intended 6 months of conservative treatment.

MAIN OUTCOME MEASURES

Scores from Roland disability questionnaire, visual analogue scale (VAS) for leg and back pain and a Likert self-rating scale of global perceived recovery were analysed.

RESULTS

There were no significant differences between groups on the 5 years' primary outcome scores. Despite at least 6 months of conservative treatment 46% of the conservatively allocated patients were treated surgically because of severe leg pain and disability. Forty-nine (21%) patients had an unsatisfactory recovery at 5 years and the recovery pattern showed that there was a variable group of 66 patients (31%) with at least one unsatisfactory outcome at 1, 2 or 5 years of follow-up. Multivariate logistic regression showed that age (>40; OR 2.42 (95% CI 1.16 to 5.02)), severity of leg pain (VAS >70; OR 3.32 (95% CI 1.69 to 6.54)) and the Mc Gill affective score (score >3; OR 6.23 (95% CI 2.23 to 17.38)) were the only significant predictors for an unsatisfactory outcome at 5 years.

CONCLUSIONS

In the long term, 8% of the patients with sciatica never showed any recovery and in at least 23%, sciatica appears to result in ongoing complaints, which fluctuate over time, irrespective of treatment. Prolonged conservative care might give patients a fair chance for pain and disability to resolve without surgery, but with the risk to receive delayed surgery after prolonged suffering of sciatica. Age above 40 years, severe leg pain at baseline and a higher affective Mc Gill pain score were predictors for unsatisfactory recovery. Trial Registry ISRCT No 26872154.

Systematic review of prognostic factors predicting outcome in non-surgically treated patients with sciatica

Identification of prognostic factors for surgery in patients with sciatica is important to be able to predict surgery in an early stage. Identification of prognostic factors predicting persistent pain, disability and recovery are important for better understanding of the clinical course, to inform patient and physician and support decision making. Consequently, we aimed to systematically review prognostic factors predicting outcome in non-surgically treated patients with sciatica. A search of Medline, Embase, Web of Science and Cinahl, up to March 2012 was performed for prospective cohort studies on prognostic factors for non-surgically treated sciatica. Two reviewers independently selected studies for inclusion and assessed the risk of bias. Outcomes were pain, disability, recovery and surgery. A best evidence synthesis was carried out in order to assess and summarize the data. The initial search yielded 4392 articles of which 23 articles reporting on 14 original cohorts met the inclusion criteria. High clinical, methodological and statistical heterogeneity among studies was found. Reported evidence regarding prognostic factors predicting the outcome in sciatica is limited. The majority of factors that have been evaluated, e.g., age, body mass index, smoking and sensory disturbance, showed no association with outcome. The only positive association with strong evidence was found for leg pain intensity at baseline as prognostic factor for subsequent surgery.

A single question was as predictive of outcome as the Tampa Scale for Kinesiophobia in people with sciatica: an observational study

QUESTION

In people with sciatica in primary care, can a single question be used to predict outcome at 1 year followup as accurately as validated questionnaires on kinesiophobia, disability, and health-related quality of life?

DESIGN

Observational study within a randomised cohort.

PARTICIPANTS

135 people with sciatica in primary care.

OUTCOME MEASURES

Kinesiophobia was measured with the Tampa Scale for Kinesiophobia (TSK), disability with the Roland Morris Disability Questionnaire (RDQ), and health-related quality of life with the EQ-5D and the 36-item Short Form (SF-36) Physical Component Summary. Participants also answered a newly devised substitute question for each questionnaire on an 11-point numerical rating scale. Global perceived effect and severity of leg pain were recorded at 1 year follow-up.

RESULTS

The correlation coefficient between the TSK and its substitute question was r=0.46 (p<0.001). The substitute question was better at predicting pain severity in the leg at 1 year follow-up than the TSK (addition of explained variation of 11% versus 4% in a logistic regression analysis). The TSK and its substitute question did not significantly differ in their prediction of global perceived effect at 1 year follow-up. The other substitute questions and both the RDQ and EQ-5D did not contribute significantly to one or both of their prediction models.

CONCLUSION

It may be feasible to replace the TSK by a single substitute question for predicting outcome in people with sciatica in primary care. The other substitute questions did not consistently predict outcome at 1 year follow-up.

Pain intensity the first year after lumbar disc herniation is associated with the A118G polymorphism in the opioid receptor mu 1 gene: evidence of a sex and genotype interaction

Earlier studies have shown that the single nucleotide polymorphism (SNP) A118G (rs1799971) in the opioid receptor mu 1 (OPRM1) gene may affect pain sensitivity. In the present study we investigated whether the A118G SNP could predict clinical outcome regarding progression of pain intensity and disability in patients with low back pain and sciatica after lumbar disc herniation. Patients (n = 258) with lumbar disc herniation and sciatic pain, all European-Caucasian, were recruited from two hospitals in Norway. Pain and disability were rated on a visual analog scale (VAS), by McGill Sensory Questionnaire and by Oswestry Disability Index (ODI) over a 12 months period. The data revealed a significant interaction between sex and A118G genotype regarding the pain intensity during the 12 months (VAS, p = 0.002; McGill, p = 0.021; ODI, p = 0.205, repeated-measures ANOVA). We found that */G women had a slower recovery rate than the */G men. Actually, the */G women had 2.3 times as much pain as the */G men 12 months after the disc herniation (VAS, p = 0.043, one-way ANOVA; p = 0.035, Tukey HSD). In contrast, the A/A women and A/A men seemed to have almost exactly the same recovery rate. The present data suggest that OPRM1 G allele increases the pain intensity in women, but has a protective effect in men the first year after disc herniation.

Prognostic factors for non-success in patients with sciatica and disc herniation

BACKGROUND

Few studies have investigated prognostic factors for patients with sciatica, especially for patients treated without surgery. The aim of this study was to identify factors associated with non-success after 1 and 2 years of follow-up and to test the prognostic value of surgical treatment for sciatica.

METHODS

The study was a prospective multicentre observational study including 466 patients with sciatica and lumbar disc herniation. Potential prognostic factors were sociodemographic characteristics, back pain history, kinesiophobia, emotional distress, pain, comorbidity and clinical examination findings. Study participation did not alter treatment considerations for the patients in the clinics. Patients reported on the questionnaires if surgery of the disc herniation had been performed. Uni- and multivariate logistic regression analyses were used to evaluate factors associated with non-success, defined as Maine-Seattle Back Questionnaire score of ≥5 (0-12) (primary outcome) and Sciatica Bothersomeness Index ≥7 (0-24) (secondary outcome).

RESULTS

Rates of non-success were at 1 and 2 years 44% and 39% for the main outcome and 47% and 42% for the secondary outcome. Approximately 1/3 of the patients were treated surgically. For the main outcome variable, in the final multivariate model non-success at 1 year was significantly associated with being male (OR 1.70 [95% CI; 1.06 - 2.73]), smoker (2.06 [1.31 - 3.25]), more back pain (1.0 [1.01 - 1.02]), more comorbid subjective health complaints (1.09 [1.03 - 1.15]), reduced tendon reflex (1.62 [1.03 - 2.56]), and not treated surgically (2.97 [1.75 - 5.04]). Further, factors significantly associated with non-success at 2 years were duration of back problems >; 1 year (1.92 [1.11 - 3.32]), duration of sciatica >; 3 months (2.30 [1.40 - 3.80]), more comorbid subjective health complaints (1.10 [1.03 - 1.17]) and kinesiophobia (1.04 [1.00 - 1.08]). For the secondary outcome variable, in the final multivariate model, more comorbid subjective health complaints, more back pain, muscular weakness at clinical examination, and not treated surgically, were independent prognostic factors for non-success at both 1 and 2 years.

CONCLUSIONS

The results indicate that the prognosis for sciatica referred to secondary care is not that good and only slightly better after surgery and that comorbidity should be assessed in patients with sciatica. This calls for a broader assessment of patients with sciatica than the traditional clinical assessment in which mainly the physical symptoms and signs are investigated.

Pulsed radiofrequency treatment adjacent to the lumbar dorsal root ganglion for the management of lumbosacral radicular syndrome: a clinical audit

INTRODUCTION

Lumbosacral radicular syndrome (LRS) is probably the most frequent neuropathic pain syndrome. Three months to 1 year after onset, 30% of the patients still experience ongoing pain. The management of those patients is complex, and treatment success rates are rather low. The beneficial effect of pulsed radiofrequency (PRF) therapy has been described for the treatment of LRS in case reports and in retrospective and prospective studies. Up until now, no neurological complications have been reported after PRF treatment. The current clinical audit has been performed to assess the amount of pain relief after a single PRF treatment.

METHODS

Sixty consecutive patients who received a PRF treatment adjacent to the lumbar dorsal root ganglion for the management of LRS in the period 2007-2009 were included. The main study objective was to measure the reduction of pain after the pulsed radiofrequency treatment by using the global perceived effect. The primary end point was defined as at least 50% pain relief for a period of 2 months or longer.

RESULTS

The primary end point was achieved in 29.5% of all the PRF interventions. After 6 months, 50% pain relief was still present in 22.9% of the cases and after 12 months in 13.1% of the cases. The need for pain medication was significantly lower after pulsed radiofrequency treatment in the success group compared with the nonsuccess group.

CONCLUSIONS

PRF treatment can be considered for the management of LRS patients. These results need to be confirmed in a randomized clinical trial.

Prediction of the need for an MRI after surgical treatment of symptomatic lumbar herniated disc at discharge: evaluation of the necessity for regular visits at the outpatient clinic

BACKGROUND

Surgical treatment of symptomatic lumbar disc herniations has been well established. The need for regular postoperative visits at the outpatient clinic has never been evaluated. In this study, factors predicting the need for magnetic resonance imaging, denoting an unfavorable outcome needing further evaluation, were evaluated.

METHODS

The charts of all patients who underwent first surgery for a lumbar herniated disc were evaluated. Predefined factors that could possibly be a predictive factor were collected: gender, age at surgery, level of surgical pathology, profession of the patient, and at discharge: leg pain, back pain, medication used for leg pain, new neurological deficit after the surgical procedure, and the number of days of their postoperative stay at the hospital. The factors were statistically analyzed.

RESULTS

One hundred seventy-two patients were identified. Twenty-nine patients underwent magnetic resonance imaging during their postoperative follow-up. None of the predefined factors at discharge had any predictive value.

CONCLUSIONS

The need for a regular appointment at the outpatient clinic for patients who underwent the first surgery can be questioned. Preoperatively and postoperatively, extensive instructions about postoperative issues related to work and lifestyle should be given. By Web or telephone, these patients should complete questionnaires at regular intervals to evaluate to outcome of the surgery. In case of unsuspected events, persistent, or recurrent complaints the patient should visit the clinic or outpatient clinic.

How is recovery from low back pain measured? A systematic review of the literature

Recovery is commonly used as an outcome measure in low back pain (LBP) research. There is, however, no accepted definition of what recovery involves or guidance as to how it should be measured. The objective of the study was designed to appraise the LBP literature from the last 10 years to review the methods used to measure recovery. The research design includes electronic searches of Medline, EMBASE, CINAHL, Cochrane database of clinical trials and PEDro from the beginning of 1999 to December 2008. All prospective studies of subjects with non-specific LBP that measured recovery as an outcome were included. The way in which recovery was measured was extracted and categorised according to the domain used to assess recovery. Eighty-two included studies used 66 different measures of recovery. Fifty-nine of the measures did not appear in more than one study. Seventeen measures used pain as a proxy for recovery, seven used disability or function and seventeen were based on a combination of two or more constructs. There were nine single-item recovery rating scales. Eleven studies used a global change scale that included an anchor of 'completely recovered'. Three measures used return to work as the recovery criterion, two used time to insurance claim closure and six used physical performance. In conclusion, almost every study that measured recovery from LBP in the last 10 years did so differently. This lack of consistency makes interpretation and comparison of the LBP literature problematic. It is likely that the failure to use a standardised measure of recovery is due to the absence of an established definition, and highlights the need for such a definition in back pain research.

Clinical factors of importance for outcome after lumbar disc herniation surgery: long-term follow-up

Factors as age, sex, smoking, duration of leg pain, working status, type/level of disc herniation and psychosocial factors have been demonstrated to be of importance for short-term results after lumbar discectomy. There are few studies with long-term follow-up. In this prospective study of lumbar disc herniation patients undergoing surgery, the result was evaluated at 2 and 5-10 (mean 7.3) years after surgery. Predictive factors for satisfaction with treatment and objective outcome were investigated. Out of the included 171 patients undergoing lumbar discectomy, 154 (90%) patients completed the 2-year follow-up and 140 (81%) completed the long-term follow-up. Baseline data and questionnaires about leg- and back pain intensity (VAS), duration of leg pain, disability (Oswestry Disability Index), depression (Zung Depression Scale), sick leave and employment status were obtained preoperatively, at 2-year- and long-term follow-up. Primary outcome included patient satisfaction with treatment (at both time points) and assessment of an independent observer at the 2-year follow-up. Secondary outcomes at 2-year follow-up were improvement of leg and back pain, working capacity and the need for analgesics or sleeping pills. In about 70% of the patients excellent or good overall result was reported at both follow-ups, with subjective outcome measurements. The objective evaluation after 2 years was in agreement with this result. Time on sick leave was found to be a clinically important predictor of the primary outcomes, with a potential of changing the probability of a satisfactory outcome (both objective and subjective) from around 50% (sick leave >3 months) to 80% (sick leave <2 months). Time on sick leave was also an important predictor for several of the secondary outcomes; e.g. working capacity and the need for analgesics.