Clinical classification criteria for radicular pain caused by lumbar disc herniation: the radicular pain caused by disc herniation (RAPIDH) criteria

Musculoskeletal mimics for lumbosacral radiculopathy. Part 1: Theoretical considerations

The diagnosis of lumbosacral radiculopathy includes the exclusion of common musculoskeletal conditions that can cause similar symptoms. Neurology and physiatry physicians use history taking and physical examination findings to develop a differential diagnosis. Appropriate diagnostic testing is then utilized to narrow down this differential diagnosis to determine a working hypothesis of the cause of a patient's symptoms, leading to a treatment plan. There are stark limitations of patient symptoms and physical examination findings in making the diagnosis of lumbosacral radiculopathy and added value of a combination of symptoms and signs to distinguish patients with lumbosacral radiculopathy from patients with mimic disorders. Diagnostic tests have variable strengths and limitations in helping to confirm this diagnosis, contrasting the high sensitivity and lower specificity of magnetic resonance imaging (MRI) with the high specificity but lower sensitivity of electromyography (EMG). Further complexity is added to the task of making a diagnosis and setting a treatment plan by the fact that these disorders are common and interact with each other; they are present concomitantly in up to 25% of patients presenting for electrodiagnostic evaluation. A companion paper will review common musculoskeletal mimics of lumbosacral radiculopathy and provide tools to anchor testing for those conditions to the traditional neurological evaluation of lumbosacral radiculopathy.

Incidence of and risk factors for lumbar disc herniation with radiculopathy in adults: a systematic review

BACKGROUND

Lumbar disc herniation (LDH) with radiculopathy is associated with greater pain, disability, healthcare use, and costs compared with nonspecific low back pain. Reliable information about its incidence and risk factors were lacking.

QUESTIONS

(1) What is the incidence of lumbar disc herniation (LDH) with radiculopathy in adults? (2) What are the risk factors for LDH with radiculopathy in adults?

METHODS

Systematic review. We searched five electronic databases from 1970 to September 2023. Eligible cohort and case-control studies were identified and independently assessed for risk of bias. A qualitative best evidence synthesis of low and moderate risk of bias studies was conducted.

RESULTS

We critically reviewed 87 studies and synthesised data from 59 (68%) studies; 12 were of low and 47 of moderate risk of bias. The lower and upper bound limits of the 95% CIs of annual incidence estimates ranged from 0.3 to 2.7 per 1000 persons for surgical case definitions, from 0.04 to 1.5 per 1,000 persons for hospital-based case definitions, and from 0.1 to 298.3 per 1,000 persons for clinical case definitions. Factors associated with the development of LDH with radiculopathy included middle-age (30-50 years), smoking, higher BMI, presence of cardiovascular risk factors (in women), and greater cumulative occupational lumbar load by forward bending postures and manual materials handling, with effect sizes ranging from ranging from 1.1 (1.0-1.3) to 3.7 (2.3-6.0).

CONCLUSIONS

Incidence of LDH varies in different populations and according to case definition. Risk factors include individual, behavioural, and work-related variables. Our findings support the need to develop standardised case definitions that validly classify the clinical spectrum of LDH and for future low risk of bias studies examining causal relationships for LDH with radiculopathy in adults.

Pain Characteristics of the Posterior Longitudinal Ligament in Percutaneous Endoscopic Lumbar Discectomy and its Significance: A Retrospective Study

INTRODUCTION

In percutaneous endoscopic lumbar discectomy (PELD), pain occurs when the posterior longitudinal ligament (PLL) is exposed, removed, and decompressed. However, pain characteristics of the PLL stimulated in PELD have not been reported.

METHODS

A total of 932 patients underwent PELD under local anesthesia. Pain distribution and intensity were recorded on a posterior body diagram during the operation. Pain intensity was assessed by the visual analog scale scores for the back (VAS-B). The PLL specimens were collected and observed using hematoxylin-eosin (HE) staining and immunohistochemistry.

RESULTS

Patients with lumbar disc herniation (LDH) at L4/5 and L5/S1 had pain foci in different regions. The mean VAS-B scores between the ventral and dorsal sides of the PLL were 6.14 ± 0.97 and 4.80 ± 1.15, respectively (P < 0.05). The distribution of nociceptive nerve fibers in the dorsal side was uniform and scattered, while those in the ventral side were mainly distributed near the outer surface of the annulus fibrosus. The positive expression of substance P (SP) and calcitonin gene-related peptide (CGRP) was higher in the ventral side of the PLL than in the dorsal side (P < 0.0001).

CONCLUSIONS

Differences in pain distribution and intensity were observed when the PLL was incited at different spinal levels during PELD surgery.

Blood expression of NADK2 as a diagnostic biomarker for sciatica

Sciatica is characterized by radiating pain along the sciatic nerve, with a lifetime prevalence of up to 43%. This study explored blood biomarkers for sciatica using transcriptomic microarray data (GSE124272 and GSE150408). Differential gene expression analysis identified NADK2 as a potential diagnostic biomarker. A diagnostic model based on NADK2 showed strong validation performance in 200 clinical cases. Gene set enrichment analysis (GSEA) suggested a connection between NADK2 and the aminoacyl-tRNA biosynthesis pathway. In conclusion, NADK2 emerges as promising diagnostic and therapeutic targets for sciatica, significantly advancing our comprehension of potential pathogenic mechanisms and offering perspectives for early diagnosis and treatment.

EXPLORING THE FEASIBILITY OF PLATELET-RICH PLASMA INJECTIONS FOR INTERVERTEBRAL DISCOPATHY: A PILOT STUDY

Objective

This longitudinal pilot study aimed to evaluate the feasibility, safety and potential benefits of Platelet-Rich Plasma injections into the lumbar intervertebral discs in patients with low back pain and degenerative intervertebral monodiscopathy, assessing potential efficacy on disability.

Design

Longitudinal pilot study.

Methods

Six participants with chronic low back pain and lumbar degenerative intervertebral disc (monodiscopathy) disease underwent 1 Platelet-Rich Plasma injection, with a 1-year follow-up. Platelet-Rich Plasma injections were administered into the lumbar intervertebral disc, and outcomes were measured using the Roland Morris Disability Questionnaire, numeric rating scale for pain, Tampa scale for kinesiophobia and lumbar flexion range. Magnetic resonance imaging analysis assessed disc changes.

Results

No adverse events were reported. At the end of the 1-year follow-up, half of the patients showed significant improvements in disability scores at 1 year, while 3 of the 6 patients had no change. Magnetic resonance imaging revealed no significant disc changes.

Conclusion

Platelet-Rich Plasma injections show promise for some patients with low back pain and degenerative intervertebral discopathy patients. However, caution is warranted due to study limitations, including small sample size and lack of a control group. Further research is needed to define Platelet-Rich Plasma therapy protocols.

Oxidative stress mediated decrement of spinal endomorphin-2 contributes to lumbar disc herniation sciatica in rats

Increasing evidence supported that oxidative stress induced by herniated lumbar disc played important role in the formation of lumbar disc herniation sciatica (LDHS), however, the neural mechanisms underlying LDHS need further clarification. Endomorphin-2 (EM2) is the endogenous ligand for mu-opioid receptor (MOR), and there is increasing evidence implicating the involvement of spinal EM2 in neuropathic pain. In this study, using an nucleus pulposus implantation induced LDHS rat model that displayed obvious mechanical allodynia, it was found that the expression of EM2 in dorsal root ganglion (DRG) and spinal cord was significantly decreased. It was further found that oxidative stress in DRG and spinal cord was significantly increased in LDHS rats, and the reduction of EM2 in DRG and spinal cord was determined by oxidative stress dominated increment of dipeptidylpeptidase IV activity. A systemic treatment with antioxidant could prevent the forming of mechanical allodynia in LDHS rats. In addition, MOR expression in DRG and spinal cord remained unchanged in LDHS rats. Intrathecal injection of MOR antagonist promoted pain behavior in LDHS rats, and the analgesic effect of intrathecal injection of EM2 was stronger than that of endomorphin-1 and morphine. Taken together, our findings suggest that oxidative stress mediated decrement of EM2 in DRG and spinal cord causes the loss of endogenous analgesic effects and enhances the pain sensation of LDHS.

Comparison of magnetic resonance imaging findings among sciatica patients classified as centralizers or non-centralizers

OBJECTIVE

To compare if the degenerative findings from MRI differ between the sciatica patients classified as centralizers (CEN) and non-centralizers (Non-CEN) according to the McKenzie Method of mechanical diagnosis and therapy.

STUDY DESIGN

A cross-sectional study.

METHODS

Patients (N = 100) referred to a spine clinic of a single tertiary hospital for specialist consultation for sciatica. The McKenzie-based assessment was performed by the mechanical diagnosis and therapy-trained physiotherapists. Clinical data and prevalence of lumbar MRI findings were compared between the groups.

RESULTS

There was no significant difference in leg pain intensity between the groups. The Non-CEN had significantly more intense back pain, mean 56 (SD 30) and were more disabled 44 (SD 15) compared to the CEN mean 41 (SD 25) and mean 31 (11), measured with a visual analogue scale (0-100), and the Oswestry Disability Index (0-100), respectively. The CEN had more severe degenerative findings on MRI than the Non-CEN: vertebral end-plate changes were 63% and 43%; mean Pfirrmann's disc degeneration lumbar summary score was 12.8, and 10.6; and severity score of total damage was 12.0 and 10.1, respectively. There were differences neither in disc contour changes nor nerve root stenosis on MRI.

CONCLUSIONS

Sciatica patients classified as non-centralizers had significantly more severe back pain, and were significantly more disabled than centralizers, who instead had more severe degenerative findings on MRI. Thus, classification to non-centralizers by the McKenzie method seems not predict higher incidence of degenerative findings on MRI compared to centralizers.

Recommendations for terminology and the identification of neuropathic pain in people with spine-related leg pain. Outcomes from the NeuPSIG working group

ABSTRACT

Pain radiating from the spine into the leg is commonly referred to as "sciatica," "Sciatica" may include various conditions such as radicular pain or painful radiculopathy. It may be associated with significant consequences for the person living with the condition, imposing a reduced quality of life and substantial direct and indirect costs. The main challenges associated with a diagnosis of "sciatica" include those related to the inconsistent use of terminology for the diagnostic labels and the identification of neuropathic pain. These challenges hinder collective clinical and scientific understanding regarding these conditions. In this position paper, we describe the outcome of a working group commissioned by the Neuropathic Pain Special Interest Group (NeuPSIG) of the International Association for the Study of Pain (IASP) which was tasked with the following objectives: (1) to revise the use of terminology for classifying spine-related leg pain and (2) to propose a way forward on the identification of neuropathic pain in the context of spine-related leg pain. The panel recommended discouraging the term "sciatica" for use in clinical practice and research without further specification of what it entails. The term "spine-related leg pain" is proposed as an umbrella term to include the case definitions of somatic referred pain and radicular pain with and without radiculopathy. The panel proposed an adaptation of the neuropathic pain grading system in the context of spine-related leg pain to facilitate the identification of neuropathic pain and initiation of specific management in this patient population.

Eligibility Criteria of Participants in Randomized Controlled Trials Assessing Conservative Management of Cervical Radiculopathy: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

The aim of this study was to evaluate the inclusion and exclusion criteria for participants in randomized control trials (RCTs) assessing conservative management for cervical radiculopathy (CR), to determine if any consensus exists within the literature.

SUMMARY OF BACKGROUND DATA

A 2012 systematic review identified a lack of uniformity for the eligibility criteria of participants in RCTs evaluating conservative interventions for CR. Since then, a large number of RCTs have been published, signaling the need for an updated evaluation of this topic.

MATERIALS AND METHODS

We electronically searched MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO from inception to June 15, 2022, to identify RCTs assessing conservative management of CR. Information extracted was analyzed to determine the level of homogeneity and/or heterogeneity of the inclusion and exclusion criteria across studies.

RESULTS

Seventy-six RCTs met our inclusion criteria with 68 distinct trials identified. The inclusion of arm pain with or without another symptom ( i.e. numbness, paresthesia, or weakness) was required in 69.12% of trials, 50% of trials required participants to exhibit neck symptoms, and 73.53% of studies required some form of clinical examination findings, but inconsistencies existed for the number and type of tests used. Furthermore, 41.18% of trials included imaging, with 33.82% of trials requiring magnetic resonance imaging findings. The most common exclusion criteria included were the presence of red flags and cervical myelopathy in 66.18% and 58.82% of trials, respectively.

CONCLUSIONS

Overall, there is still a lack of uniformity for the inclusion/exclusion criteria of trials assessing the conservative management of CR, with some improvements noted compared with the 2012 review. Based on the current literature assessing the diagnostic utility of clinical symptoms and confirmatory tests, we proposed inclusion criteria for trials assessing conservative interventions. Future research should aim to develop standardized classification criteria to improve consistency among studies.

Modic Changes in Ecuadorian Mestizo Patients: Epidemiology, Clinical Significance, and Role in Chronic Low Back Pain

Modic changes (MC) are bone marrow lesions seen within a vertebral body on MRI, possibly associated with low back pain (LBP). Though the causes and mechanisms responsible for the formation of MC are still poorly understood, progress is being made in linking his spinal phenotype with disc degeneration and LBP. This paper analyzes the epidemiology, clinical signs, lesions type, and treatment of vertebral discopathy associated with MC in Ecuadorian mestizo patients, comparing MC type I-II changes versus MC type III differences. We performed an epidemiological, observational, cross-sectional study with two cohorts of Mestizo patients collected at "Hospital de los Valles" in Quito, Ecuador, between January 2017 and December 2020; 288 patients diagnosed with degenerative lumbar disc disease plus MC was taken who underwent surgery; 144 with MC type I-II (cohort 1) and 144 with MC type III changes (cohort 2). Cohort 1 was characterized by 68.8% of men with a mean age of 45 years who perform minimal or moderate exercise in 82% of cases. They showed only one level lesion in 88.9% of patients with a pain intensity of 7 or more on the visual analog scale, with three or more months of evolution, in 78.5% of cases of degenerative etiology, mainly between the L5-S1 lesion of the left side. Cohort 2 was 53.5% of women with a mean age of 62. In 81.4% of cases, they perform minimal or moderate exercise. They showed two-level lesions in 45.8% of patients with a pain intensity of 7 or more on the visual analog scale, with three or more months of evolution, in 97.9% of cases of degenerative etiology, mostly between L4-L5 lesions of the left side. In both groups, most patients showed a protruded and lateral hernia. There is a greater predisposition to require surgery for lumbar disc herniation in young men and older women. In addition, surgery at an older age has a higher risk of complications, especially infection.

Risk Factors, Prevention, and Primary and Secondary Management of Sciatica: An Updated Overview

Sciatica is a chronic condition causing crippling low back pain radiating down to the sciatic nerve innervation area, which is the posterior thigh. It remains a major public health problem worldwide with significant socio-economic, physical, and psychological impacts. Studies suggested different diagnostic methods due to the lack of consensus on diagnostic and treatment guidelines. When it comes to the management and treatment, there is ambiguous evidence about the use of painkillers, surgical interventions, and alternative options and their effectiveness, with most studies contrasting one another in addition to the lack of high-quality trials. This review presents the available data on the current understanding of sciatica covering clinical manifestations, diagnosis and treatment modalities, prognosis, and complications since a disagreement is observed in the scientific community regarding sciatica, starting with a definition of sciatica, its epidemiological characteristics, to the management and treatment. Our review would help raise knowledge and awareness about sciatica in the health professional community and the general public since the prevalence of low back pain is high in most parts of the world and there is insufficient knowledge of sciatica in the literature.

Identification of Immune-Related Biomarkers for Sciatica in Peripheral Blood

Objective: Sciatica pertains to neuropathic pain that has been associated with inflammatory response. We aimed to identify significant immune-related biomarkers for sciatica in peripheral blood. Methods: We utilized the GSE150408 expression profiling data from the Gene Expression Omnibus (GEO) database as the training dataset and extracted immune-related genes for further analysis. Differentially expressed immune-related genes (DEIRGs) between healthy controls and patients with sciatica were selected using the "limma" package and verified in clinical specimens by quantitative reverse transcription PCR (RT-qPCR). A diagnostic immune-related gene signature was established using the training model and random forest (RF), generalized linear model (GLM), and support vector machine (SVM) models. Sciatica patient subtypes were identified using the consensus clustering method. Results: Thirteen significant DEIRGs were acquired, of which five (CRP, EREG, FAM19A4, RLN1, and WFIKKN1) were selected to establish a diagnostic immune-related gene signature according to the most appropriate training model, namely, the RF model. A clinical application nomogram model was established based on the expression level of the five DEIRGs. The sciatica patients were divided into two subtypes (C1 and C2) according to the consensus clustering method. Conclusions: Our research established a diagnostic five immune-related gene signature to discriminate sciatica and identified two sciatica subtypes, which may be beneficial to the clinical diagnosis and treatment of sciatica.

Methods to discriminate between mechanism-based categories of pain experienced in the musculoskeletal system: a systematic review

ABSTRACT

Mechanism-based classification of pain has been advocated widely to aid tailoring of interventions for individuals experiencing persistent musculoskeletal pain. Three pain mechanism categories (PMCs) are defined by the International Association for the Study of Pain: nociceptive, neuropathic, and nociplastic pain. Discrimination between them remains challenging. This study aimed to build on a framework developed to converge the diverse literature of PMCs to systematically review methods purported to discriminate between them; synthesise and thematically analyse these methods to identify the convergence and divergence of opinion; and report validation, psychometric properties, and strengths/weaknesses of these methods. The search strategy identified articles discussing methods to discriminate between mechanism-based categories of pain experienced in the musculoskeletal system. Studies that assessed the validity of methods to discriminate between categories were assessed for quality. Extraction and thematic analysis were undertaken on 184 articles. Data synthesis identified 200 methods in 5 themes: clinical examination, quantitative sensory testing, imaging, diagnostic and laboratory testing, and pain-type questionnaires. Few methods have been validated for discrimination between PMCs. There was general convergence but some disagreement regarding findings that discriminate between PMCs. A combination of features and methods, rather than a single method, was generally recommended to discriminate between PMCs. Two major limitations were identified: an overlap of findings of methods between categories due to mixed presentations and many methods considered discrimination between 2 PMCs but not others. The results of this review provide a foundation to refine methods to differentiate mechanisms for musculoskeletal pain.

Extending the straight leg raise test for improved clinical evaluation of sciatica: reliability of hip internal rotation or ankle dorsiflexion

Background

The straight leg raise (SLR) is the most commonly applied physical tests on patients with sciatica, but the sensitivity and specificity ratings for disc hernia and neural compression leave areas for improvement. Hip internal rotation tensions the lumbosacral nerve roots and ankle dorsiflexion tensions the sciatic nerve along its course. We added these movements to the SLR (extended SLR = ESLR) as structural differentiators and tested inter-rater reliability in patients with LBP, with and without sciatica.

Methods

Forty subjects were recruited to the study by the study controller (SC), 20 in the sciatic group and in the control group. Two independent examiners (E1&E2) performed the ESLR and did not communicate to the subjects other than needed to determine the outcome of the ESLR. First, SLR was performed traditionally until first responses were evoked. At this hip flexion angle, a location-specific structural differentiation was performed to confirm whether the emerged responses were of neural origin. Cohen’s Kappa score (CK) for interrater reliability was calculated for ESLR result in detection of sciatic patients. Also, the examiners’ ESLR results were compared to the traditional SLR results.

Results

The interrater agreement between Examiner 1 and Examiner 2 for the ESLR was 0.85 (p < 0.001, 95%CI: 0.71–0.99) translating to almost perfect agreement as measured by Cohen’s Kappa When the ESLR was compared to the traditional SLR, the overall agreement rate was 75% (30/40). Kappa values between the traditional SLR and the E1’s or E2’s ESLR results were 0.50 (p < 0.0001; 95%CI 0.27–0.73) and 0.54 (p < 0.0001; 95%CI 0.30–0.77), respectively.

Conclusions

ESLR with the addition of location-specific structural differentiation is a reliable and repeatable tool in discerning neural symptoms from musculoskeletal in patients with radiating low back pain. We recommend adding these movements to the standard SLR with aim of improving diagnostic ability.

Diagnostic criteria for musculoskeletal disorders for use in occupational healthcare or research: a scoping review of consensus- and synthesised-based case definitions

BACKGROUND

The aim of this study was to identify case definitions of diagnostic criteria for specific musculoskeletal disorders (MSDs) for use in occupational healthcare, surveillance or research.

METHODS

A scoping review was performed in Medline and Web of Science from 2000 to 2020 by an international team of researchers and clinicians, using the Arksey and O'Malley framework to identify case definitions based on expert consensus or a synthesis of the literature. Seven MSDs were considered: non-specific low back pain (LBP), lumbosacral radicular syndrome (LRS), subacromial pain syndrome (SAPS), carpal tunnel syndrome (CTS), lateral or medial elbow tendinopathy, and knee and hip osteoarthritis (OA). Case definitions for occupational healthcare or research were charted according to symptoms, signs and instrumental assessment of signs, and if reported, on work-related exposure criteria.

RESULTS

In total, 2404 studies were identified of which 39 were included. Fifteen studies (38%) reported on non-specific LBP, followed by knee OA (n = 8;21%) and CTS (n = 8;21%). For non-specific LBP, studies agreed in general on which symptoms (i.e., pain in lower back) and signs (i.e., absence of red flags) constituted a case definition while for the other MSDs considerable heterogeneity was found. Only two studies (5%), describing case definitions for LBP, CTS, and SAPS and lateral and medial elbow tendinopathy respectively, included work-related exposure criteria in their clinical assessment.

CONCLUSION

We found that studies on non-specific LBP agreed in general on which symptoms and signs constitute a case definition, while considerable heterogeneity was found for the other MSDs. For prevention of work-related MSDs, these MSD case definitions should preferably include work-related exposure criteria.

Interactions between the MMP-3 gene rs591058 polymorphism and occupational risk factors contribute to the increased risk for lumbar disk herniation: A case-control study

Objective

Lumbar disk herniation (LDH) is a complex condition based on lumbar disk degeneration (LDD). Previous studies have shown that genetic factors are highly associated with the severity and risk for LDH. This case‐control study was aimed to evaluate the association between the matrix metalloproteinase (MMP)‐3 gene rs591058 C/T polymorphism and LDH risk in a southern Chinese population.

Methods

A total of 231 LDH patients and 312 healthy controls were recruited in this study. Genotyping was analyzed using a standard polymerase chain reaction and restriction fragment length polymorphism (PCR‐RFLP).

Results

It was observed that TT genotype or T allele carriers of the MMP‐3 gene rs591058 C/T polymorphism was more likely associated with an increased risk for LDH. Subgroup analyses showed the following characteristics increased the risk for LDH: female sex; cigarette smoking; and alcohol consumption. Furthermore, individuals with high whole body vibration, bending/twisting, and lifting were associated with an increased risk for LDH.

Conclusion

Taken together, these data indicated that the MMP‐3 gene rs591058 C/T polymorphism was associated with an increased risk for LDH. The MMP‐3 gene rs591058 C/T polymorphism might serve as a clinical indicator and marker for LDH risk in the Chinese population.

Stratified care versus usual care for management of patients presenting with sciatica in primary care (SCOPiC): a randomised controlled trial

Background

Sciatica has a substantial impact on individuals and society. Stratified care has been shown to lead to better outcomes among patients with non-specific low back pain, but it has not been tested for sciatica. We aimed to investigate the clinical and cost-effectiveness of stratified care versus non-stratified usual care for patients presenting with sciatica in primary care.

Methods

We did a two-parallel arm, pragmatic, randomised controlled trial across three centres in the UK (North Staffordshire, North Shropshire/Wales, and Cheshire). Eligible patients were aged 18 years or older, had a clinical diagnosis of sciatica, access to a mobile phone or landline number, were not pregnant, were not currently receiving treatment for the same problem, and had no previous spinal surgery. Patients were recruited from general practices and randomly assigned (1:1) by a remote web-based service to stratified care or usual care, stratified by centre and stratification group allocation. In the stratified care arm, a combination of prognostic and clinical criteria associated with referral to spinal specialist services were used to allocate patients to one of three groups for matched care pathways. Group 1 was offered brief advice and support in up to two physiotherapy sessions; group 2 was offered up to six physiotherapy sessions; and group 3 was fast-tracked to MRI and spinal specialist assessment within 4 weeks of randomisation. The primary outcome was self-reported time to first resolution of sciatica symptoms, defined as “completely recovered” or “much better” on a 6-point ordinal scale, collected via text messages or telephone calls. Analyses were by intention to treat. Health-care costs and cost-effectiveness were also assessed. This trial is registered on the ISRCTN registry, ISRCTN75449581.

Findings

Between May 28, 2015, and July 18, 2017, 476 patients from 42 general practices around three UK centres were randomly assigned to stratified care or usual care (238 in each arm). For the primary outcome, the overall response rate was 89% (9467 of 10 601 text messages sent; 4688 [88%] of 5310 in the stratified care arm and 4779 [90%] of 5291 in the usual care arm). Median time to symptom resolution was 10 weeks (95% CI 6·4–13·6) in the stratified care arm and 12 weeks (9·4–14·6) in the usual care arm, with the survival analysis showing no significant difference between the arms (hazard ratio 1·14 [95% CI 0·89–1·46]). Stratified care was not cost-effective compared to usual care.

Interpretation

The stratified care model for patients with sciatica consulting in primary care was not better than usual care for either clinical or health economic outcomes. These results do not support a transition to this stratified care model for patients with sciatica.

Funding

National Institute for Health Research.

Inadequacies of the Lasègue test, and how the Slump and Bowstring tests are useful for the diagnosis of sciatica

Diagnosis of sciatica mainly relies on pain reproduction by stretching of the lumbar roots since neurological examination and medical history are usually not sufficient to guarantee diagnosis. The Lasègue test is the most popular method, which starts with the straight leg-raising test (SLR). However it is not perfect, and is not always well performed or interpreted. Passive ankle dorsiflexion at the end of the SLR (Bragard test) is more sensitive, but can also remain normal in some cases of sciatica. Other stretching tests can help to recognise lumbar root damage in patients with poorly defined pain in a lower extremity: firstly, the Christodoulides test, i.e. reproduction of L5 sciatic pain by a femoral stretch test; secondly, the Slump test, performed on a patient in a sitting position, by slowly extending their painful leg then passively bending their neck (or the opposite); and thirdly, the Bowstring test, which requires, at the end of the Lasègue test, once the knee has been slightly flexed, pressing on the course of the peroneal and/or tibial nerves in the popliteal fossea to try and reproduce the exact pain felt by the patient. The combination of all these tests takes less than 2minutes, and could improve both the sensitivity and specificity of the physical examination for the diagnosis of sciatica. This article is a review of the limitations of the Lasègue/SLR tests and of the efficacy of these other tests for stretching the lumbar roots.

Reliability of the Buttock Applied Strain Test to Diagnose Radicular Pain in Patients With Low Back Pain

BACKGROUND

Low-back pain (LBP) pathophysiological conditions include nociceptive back pain, somatic referred pain, radicular pain (RP), and radiculopathy. Differential diagnosis is challenging; guidance may come from patients' thorough clinical history and physical examination and, particularly for lumbar RP, from the evaluation of subjective responses of injured lumbar nerves to a strain applied at the buttock (buttock applied strain [BUAS] test).

METHODS

In a sample of 395 consecutive patients with LBP, sensitivity, specificity, and prior probability (positive predictive values [PPVs] and negative predictive values [NPVs]) of the BUAS test were evaluated against 2 reference tests: the straight leg raising test (SLRT) and the painDETECT (PD) questionnaire. Multinomial logistic regression (MLR) and χ² analyses were used to evaluate the BUAS test outcomes' dependence upon independent variables (gender, age group, pain localization, SLRT outcomes, and PD outcomes). Cohen's kappa statistic was used to assess inter-rater agreement.

RESULTS

Compared with the PD questionnaire, the BUAS test showed a sensitivity of 92%, specificity of 100%, PPV of 100%, and NPV of 82%; compared with the SLRT, the BUAS test showed a sensitivity of 82%, NPV of 82%, specificity of 40%, and PPV of 40%. Inter-rater agreement of Cohen's kappa was 0.911. Significant associations were found between BUAS test outcomes and pain localization, SLRT outcomes, and PD outcomes, but not with the predictors gender or age group. MLR showed significant congruent relationships between BUAS test and PD outcomes.

CONCLUSION

Among patients with LBP, the BUAS test showed satisfactory sensitivity, specificity, prior probability, and inter-rater reliability; thus, it may be considered a useful adjunctive tool to diagnose RP in patients with LBP. For more generalized results, more research, in clinical settings other than pain clinics, is needed.

Subgrouping patients with sciatica in primary care for matched care pathways: development of a subgrouping algorithm

Background

Sciatica is a painful condition managed by a stepped care approach for most patients. Currently, there are no decision-making tools to guide matching care pathways for patients with sciatica without evidence of serious pathology, early in their presentation. This study sought to develop an algorithm to subgroup primary care patients with sciatica, for initial decision-making for matched care pathways, including fast-track referral to investigations and specialist spinal opinion.

Methods

This was an analysis of existing data from a UK NHS cohort study of patients consulting in primary care with sciatica (n = 429). Factors potentially associated with referral to specialist services, were identified from the literature and clinical opinion. Percentage of patients fast-tracked to specialists, sensitivity, specificity, positive and negative predictive values for identifying this subgroup, were calculated.

Results

The algorithm allocates patients to 1 of 3 groups, combining information about four clinical characteristics, and risk of poor prognosis (low, medium or high risk) in terms of pain-related persistent disability. Patients at low risk of poor prognosis, irrespective of clinical characteristics, are allocated to group 1. Patients at medium risk of poor prognosis who have all four clinical characteristics, and patients at high risk of poor prognosis with any three of the clinical characteristics, are allocated to group 3. The remainder are allocated to group 2. Sensitivity, specificity and positive predictive value of the algorithm for patient allocation to fast-track group 3, were 51, 73 and 22% respectively.

Conclusion

We developed an algorithm to support clinical decisions regarding early referral for primary care patients with sciatica. Limitations of this study include the low positive predictive value and use of data from one cohort only. On-going research is investigating whether the use of this algorithm and the linked care pathways, leads to faster resolution of sciatica symptoms.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2686-x) contains supplementary material, which is available to authorized users.

Nonsurgical medical treatment in the management of pain due to lumbar disc prolapse: A network meta-analysis

BACKGROUND

Evaluate the comparative effectiveness of treatment strategies for patients with pain due to lumbar disc prolapse (LDP).

METHODS

PubMed, EMBASE, and the Cochrane Database were searched through September 2017. Randomized controlled trials on LDP reporting on pain intensity and/or global pain effects which compared included treatments head-to-head, against placebo, and/or against conventional care were included. Study data were independently double-extracted and data on patient traits and outcomes were collected. Risk of bias was assessed using the Cochrane risk of bias tool. Separate Bayesian network meta-analyses were undertaken to synthesize direct and indirect, short-term and long-term outcomes, summarized as odds ratios (OR) or weighted mean differences (WMD) with 95% credible intervals (CI) as well as surface under the cumulative ranking curve (SUCRA) values.

RESULTS

58 studies in global effects and 74 studies in pain intensity analysis were included. Thirty-eight (65.5%) of these studies reported a possible elevated risk of bias. Autonomic drugs and transforminal epidural steroid injections (TESIs) had the highest SUCRA scores at short-term follow up (86.7 and 83.5 respectively), while Cytokines/Immunomodulators and TESI had the highest SUCRA values at long-term-follow-up in the global effect's analysis (86.6 and 80.9 respectively). Caudal steroid injections and TESIs had the highest SUCRA scores at short-term follow up (79.4 and 75.9 respectively), while at long-term follow-up biological agents and manipulation had the highest SUCRA scores (86.4 and 68.5 respectively) for pain intensity. Some treatments had few studies and/or no associated placebo-controlled trials. Studies often did not report on co-interventions, systematically differed, and reported an overall elevated risk of bias.

CONCLUSION

No treatment stands out as superior when compared on multiple outcomes and time periods but TESIs show promise as an effective short-term treatment. High quality studies are needed to confirm many nodes of this network meta-analysis.

The modified transforaminal endoscopic technique in treating intracanalicular combining foraminal and/or extraforaminal lumbar disc herniations

Background

To develop a modified transforaminal endoscopic spine system (TESSYS^®) technique for treating intracanalicular combining foraminal and/or extraforaminal lumbar disc herniation (ICFE-LDH), and evaluate the technical efficacy and safety.

Methods

Twenty-three patients with ICFE-LDH underwent the modified TESSYS technique were enrolled. Magnetic resonance imaging (MRI) was used to verify the reduction of herniated disc. Pre- and post-operative neurological functions were compared by visual analogue scale (VAS) score, Oswestry disability index (ODI) and the modified MacNab criteria. The technical safety was evaluated by surgical complications.

Results

MRI demonstrated reductions of disc herniations in 22 patients (95.7%) after surgeries. The VAS scores were significantly improved at 1 year follow-up (low back: P=0.001, lower limbs: P<0.001), as well as ODI scores (P<0.001). 22 patients had achieved excellent and good recovery postoperatively according to the modified MacNab criteria. One patient (4.3%) underwent a reoperation due to postoperative recurrence of disc herniation. Another patient complained postoperative causalgia in 8 weeks, the symptom alleviated after conservative treatment at 1 year follow-up (VAS: back, 3, lower limbs, 0; ODI: 20%). The incidence rate of surgical complication was 8.7%.

Conclusions

The modified TESSYS technique is a minimally-invasive, effective and safe surgery for treating ICFE-LDHs in selected patients.

Clinical classification criteria for neurogenic claudication caused by lumbar spinal stenosis. The N-CLASS criteria

BACKGROUND CONTEXT

Because imaging findings of lumbar spinal stenosis (LSS) may not be associated with symptoms, clinical classification criteria based on patient symptoms and physical examination findings are needed.

PURPOSE

The objective of this study was to develop clinical classification criteria that identify patients with neurogenic claudication (NC) caused by LSS.

STUDY DESIGN

This study is a two-stage process that includes Phase 1, the Delphi process, and Phase 2, the cross-sectional study.

PATIENT SAMPLE

Outpatients were recruited from spine clinics in five countries.

OUTCOME MEASURE

The outcome measure includes items from the patients' history and physical examination.

METHODS

In Phase 1, a list of potential predictors of NC caused by LSS was based on the available literature and was evaluated through a Delphi process involving 17 spine specialists (surgeons and non-surgeons) from eight countries. In Phase 2, 19 different clinical spine specialists from five countries identified patients they classified as having (1) NC caused by LSS, (2) radicular pain caused by lumbar disc herniation (LDH), or (3) non-specific low back pain (NSLBP) with radiating leg pain. The patients completed survey items and the specialists documented the examination signs. Coefficients from general estimating equation models were used to select predictors, to generate a clinical classification score, and to obtain a receiver operating characteristic curve. Conduction of the Delphi process, data management, and statistical analysis were partially supported by an unrestricted grant of less than 15,000 US dollars from Merck Sharp & Dohme. No fees were allocated to participating spine specialists.

RESULTS

Phase 1 generated a final list of 46 items related to LSS. In Phase 2, 209 patients with leg pain caused by LSS (n=63), LDH (n=89), or NSLBP (n=57) were included. Criteria that independently predicted NC (p<.05) were age over 60 years, positive 30-second extension test, negative straight leg test, pain in both legs, leg pain relieved by sitting, and leg pain decreased by leaning forward or flexing the spine. A classification score using a weighted set of these criteria was developed. The proposed N-CLASS score ranged from 0 to 19 and had an area under the curve of 0.92, and the cutoff (>10/19) to obtain a specificity of >90.0% resulted in a sensitivity of 82.0%.

CONCLUSIONS

Clinical criteria independently associated with neurogenic claudication due to LSS were identified. The use of these symptom and physical variables as a classification score for clinical research could improve homogeneity among enrolled patients.

Development and clinical application of grading and classification criteria of lumbar disc herniation

This study aimed to develop new grading and classification criteria for lumbar disc herniation (LDH). First, from January 1993 to January 2003, we collected the detailed information of 1127 patients with LDH and, based on that information, developed a new grading classification termed the 6-score-V-type criteria wherein conservative treatment is recommended for patients with type I, II, or IIIA, surgical treatment is recommended for type IIIC, IV, and V, and 3 months of conservative followed by surgery if no improvements are obtained during the conservative treatment period is recommended for type IIIBe. The distribution of types among the 1,127 patients was: type I (7.9%), type II (22.9%), type III (34.1%), type IV (22.2%), and type V (12.6%). Type III cases were subdivided into type IIIA (9.9%), type IIIB (13.3%), and IIIC (10.8%). Second, from February 2003 to December 2009, we treated a separate group of 1130 patients with LDH according to this 6-score-V-type classification rubric and monitored them for 24 months. Therapeutic efficacy was assessed in 1130 patients with a standard evaluation for leg pain. Overall, 85.3% of the patients in the first year and 84.1% in the second year had good or excellent response ratings. The inter-examiner reliability was 98%. Assignment of therapeutic protocols according to the 6-score-V-type classification yielded satisfactory outcomes, indicating that the 6-score-V-type criteria are straightforward and practical.