Lumbosacral radiculopathies: conservative approaches to management

ACUTE RADIATING LOW BACK PAIN IMPACT ON ROUTINE AND FUNCTION OF THE BRAZILIAN POPULATION: A CROSS-SECTIONAL STUDY

Acute radiating low back pain is a frequently occurring clinical condition among the population, and it represents a significant portion of urgent care in public health services.

Objective

Consider the clinical characteristics, demographics, as well as the intensity of the pain, discomfort, and dysfunction of patients who show a clinical diagnosis that is compatible with acute radicular pain, new or reoccurring after an asymptomatic period.

Methods

Patients that display a clinical diagnosis that is compatible with acute sciatic nerve pain, with the beginning of it starting within three months, without previous history of a similar occurrence, were seen in an orthopedic health clinic from July 2020 to January 2021.

Results

A total of 42 patients were seen with a compatible diagnosis, which represents 1.4% of all medical visits. To the best of our knowledge, no studies have considered the clinical and demographic characteristics of patients with acute radicular pain in the Brazilian population. This study has found a mean value on the disfunction index that is greater than what is suggested by the current literature.

Conclusion

About 30% of individuals showed functional involvement that was considered crippling, which presented a stronger association with individuals with the presence of motor deficits, intensity of radiating pain, and professional inactivity. Level of Evidence IV, Cross-Sectional Study.

Intradiscal oxygen-ozone chemonucleolysis versus microdiscectomy for lumbar disc herniation radiculopathy: a non-inferiority randomized control trial

BACKGROUND CONTEXT

Low back pain with or without radicular leg pain is an extremely common health condition significantly impacting patient's activities and quality of life. When conservative management fails, epidural injections providing only temporary relief, are frequently utilized. Intradiscal oxygen-ozone may offer an alternative to epidural injections and further reduce the need for microdiscectomy.

PURPOSE

To compare the non-inferiority treatment status and clinical outcomes of intradiscal oxygen-ozone with microdiscectomy in patients with refractory radicular leg pain due to single-level contained lumbar disc herniations.

STUDY DESIGN / SETTING

Multicenter pilot prospective non-inferiority blocked randomized control trial conducted in three European hospital spine centers.

PATIENT SAMPLE

Forty-nine patients (mean 40 years of age, 17 females/32 males) with a single-level contained lumbar disc herniation, radicular leg pain for more than six weeks, and resistant to medical management were randomized, 25 to intradiscal oxygen-ozone and 24 to microdiscectomy. 88% (43 of 49) received their assigned treatment and constituted the AS-Treated (AT) population.

OUTCOME MEASURES

Primary outcome was overall 6-month improvement over baseline in leg pain. Other validated clinical outcomes, including back numerical rating pain scores (NRS), Roland Morris Disability Index (RMDI) and EQ-5D, were collected at baseline, 1 week, 1-, 3-, and 6-months. Procedural technical outcomes were recorded and adverse events were evaluated at all follow-up intervals.

METHODS

Oxygen-ozone treatment performed as outpatient day surgeries, included a one-time intradiscal injection delivered at a concentration of 35±3 μg/cc of oxygen-ozone by a calibrated delivery system. Discectomies performed as open microdiscectomy inpatient surgeries, were without spinal instrumentation, and not as subtotal microdiscectomies. Primary analyses with a non-inferiority margin of -1.94-point difference in 6-month cumulative weighted mean leg pain NRS scores were conducted using As-Treated (AT) and Intent-to-Treat (ITT) populations. In post hoc analyses, differences between treatment groups in improvement over baseline were compared at each follow-up visit, using baseline leg pain as a covariate.

RESULTS

In the primary analysis, the overall 6-month difference between treatment groups in leg pain improvement using the AT population was -0.31 (SE, 0.84) points in favor of microdiscectomy and using the ITT population, the difference was 0.32 (SE, 0.88) points in favor of oxygen-ozone. The difference between oxygen-ozone and microdiscectomy did not exceed the non-inferiority 95% confidence lower limit of treatment difference in either the AT (95% lower limit, -1.72) or ITT (95% lower limit, -1.13) populations. Both treatments resulted in rapid and statistically significant improvements over baseline in leg pain, back pain, RMDI, and EQ-5D that persisted in follow-up. Between group differences were not significant for any outcomes. During 6-month follow-up, 71% (17 of 24) of patients receiving oxygen-ozone, avoided microdiscectomy. The mean procedure time for oxygen-ozone was significantly faster than microdiscectomy by 58 minutes (p<.0010) and the mean discharge time from procedure was significantly shorter for the oxygen-ozone procedure (4.3±2.9 hours vs. 44.2±29.9 hours, p<.001). No major adverse events occurred in either treatment group.

CONCLUSIONS

Intradiscal oxygen-ozone chemonucleolysis for single-level lumbar disc herniations unresponsive to medical management, met the non-inferiority criteria to microdiscectomy on 6-month mean leg pain improvement. Both treatment groups achieved similar rapid significant clinical improvements that persisted and overall, 71% undergoing intradiscal oxygen-ozone were able to avoid surgery.

The impact of low back-related leg pain on outcomes as compared with low back pain alone: a systematic review of the literature

OBJECTIVES

Low back pain (LBP) with leg pain, especially with findings of nerve root involvement, is considered as a poor prognostic indicator although it seems to have a favorable natural resolution. It is unclear whether patients with LBP and leg pain are at the more severe end of the spectrum as compared with patients with LBP alone or whether they are a distinct subgroup that would perhaps benefit from early identification of the condition and more targeted interventions. The purpose of this study was to investigate the impact of LBP-related leg pain on outcomes and use of health resources as compared with patients with LBP alone.

METHODS

Systematic review of studies reporting separate outcomes of patients with LBP and LBP with leg pain and synthesis of available evidence. Literature search of all English language peer-reviewed publications was conducted using MEDLINE, EMBASE, and CINAHL for the years 1994 to 2010.

RESULTS

Of the papers retrieved, 9 were included in the review. The heterogeneity of studies allowed only narrative analysis of findings. All studies reported worse health outcomes and increased use of health care with radiation of leg pain distally and with neurological findings, with the exception of psychological outcomes.

DISCUSSION

LBP with pain radiating to the leg appears to be associated with increased pain, disability, poor quality of life, and increased use of health resources compared with LBP alone. These findings argue for early identification of these cases by health care professionals and pursuing effective treatments.

Clinical course, characteristics and prognostic indicators in patients presenting with back and leg pain in primary care. The ATLAS study protocol

BACKGROUND

Low-back related leg pain with or without nerve root involvement is associated with a poor prognosis compared to low back pain (LBP) alone. Compared to the literature investigating prognostic indicators of outcome for LBP, there is limited evidence on prognostic factors for low back-related leg pain including the group with nerve root pain. This 1 year prospective consultation-based observational cohort study will describe the clinical, imaging, demographic characteristics and health economic outcomes for the whole cohort, will investigate differences and identify prognostic indicators of outcome (i.e. change in disability at 12 months), for the whole cohort and, separately, for those classified with and without nerve root pain. In addition, nested qualitative studies will provide insights on the clinical consultation and the impact of diagnosis and treatment on patients' symptom management and illness trajectory.

METHODS

Adults aged 18 years and over consulting their General Practitioner (GP) with LBP and radiating leg pain of any duration at (n = 500) GP practices in North Staffordshire and Stoke-on-Trent, UK will be invited to participate. All participants will receive a standardised assessment at the clinic by a study physiotherapist and will be classified according to the clinically determined presence or absence of nerve root pain/involvement. All will undergo a lumbar spine MRI scan. All participants will be managed according to their clinical need. The study outcomes will be measured at 4 and 12 months using postal self-complete questionnaires. Data will also be collected each month using brief postal questionnaires to enable detailed description of the course of low back and leg pain over time. Clinical observations and patient interviews will be used for the qualitative aspects of the study.

DISCUSSION

This prospective clinical observational cohort will combine self-reported data, comprehensive clinical and MRI assessment, together with qualitative enquiries, to describe the course, health care usage, patients' experiences and prognostic indicators in an adult population presenting in primary care with LBP and leg pain with or without nerve root involvement.

Clinical outcomes among low back pain consulters with referred leg pain in primary care

STUDY DESIGN

Merged data from two primary care prospective cohort studies.

OBJECTIVE

To compare the clinical course of low back pain (LBP) consulters to primary care with and without self-reported referred leg pain.

SUMMARY OF BACKGROUND DATA

In patients with LBP, the presence of leg pain/sciatica is considered a poor prognostic indicator, associated with more severe pain, disability, and time off work. However, questions remain about how best to identify sciatica in primary care and whether self-reported referred leg pain provides a distinct classification for primary care.

METHODS

Data from two large prospective cohort studies of consecutive patients consulting with LBP in 13 general practices were merged. Using self-report data patients were divided into three subgroups: (1) those with LBP alone, (2) LBP with referred pain above the knee (LBP + above-knee), and (3) LBP with referred pain below the knee (LBP + below-knee). Unadjusted and adjusted baseline and 6-month follow-up scores on physical, psychological, and social indicators were compared between the groups using multiple regression analysis.

RESULTS

Among 1247 consulters the baseline prevalence of cases with LBP alone was 465 (37%), LBP + above-knee was 308 (25%), and LBP + below-knee was 474 (38%). Baseline severity and 6-month outcomes in the consulters with referred leg pain were significantly worse compared to those with LBP alone across a wide range of clinical characteristics, although differences diminished after adjusting for baseline characteristics.

CONCLUSION

The clinical course for LBP with self-reported referred leg pain is much worse. However, the fact that differences in outcome were not worse after adjustment suggests that baseline differences in severity and duration of back pain, demographic, and psychological characteristics largely explain the poorer outcomes in patients with referred leg pain. Future research needs to establish if similar results are observed among patients with clinically determined sciatica.

Development of an assessment schedule for patients with low back-associated leg pain in primary care: a Delphi consensus study

Purpose

The objectives of this study were to develop consensus on (i) the content of a clinical assessment for adults presenting to primary care with low back and leg pain, and (ii) the most important items for diagnosing spinal nerve root involvement.

Methods

Existing literature and expert knowledge was used to compile a list of items pertaining to clinical history questions and examination tests employed in the assessment of patients with low back pain with suspected spinal nerve involvement. A Delphi consensus method was employed to rate the importance of items for clinical assessment and for diagnosis in two web-based rounds. A multidisciplinary group of 42, including GPs, physiotherapists, osteopaths, rheumatologists, spinal orthopaedic surgeons and chiropractors took part. Items were included in the final assessment when over 70% of participants rated them as important.

Results

Thirty-four items were included in the clinical assessment, and 15 items for diagnosis. History items included pain distribution in the leg, pain quality and behaviour, altered sensation, functional limitations and yellow flags, previous history of similar symptoms and outcome of previous treatment/management. Examination items included typical neurological tests including neural tension and ‘demonstration of movement that produces symptoms’.

Conclusions

We have developed a clinical assessment schedule for patients with low back pain and leg pain presenting in primary care. History and clinical items considered important for their contribution in the diagnosis of nerve root involvement were also established.

Electronic supplementary material

The online version of this article (doi:10.1007/s00586-011-2057-2) contains supplementary material, which is available to authorized users.

Sciatica: review of epidemiological studies and prevalence estimates

STUDY DESIGN

Review of studies on sciatica prevalence and synthesis of available evidence.

OBJECTIVE

To assess the studies on sciatica prevalence, discuss reasons for variation in estimates, provide suggestions for improving accuracy of recording sciatica in epidemiological and outcome studies so as to enable better evaluation of natural history and treatment effect in the presence of low back pain related sciatica.

SUMMARY OF BACKGROUND DATA

Sciatica is a common cause of pain and disability. It is more persistent and severe than low back pain, has a less favorable outcome and consumes more health resources. However, sciatica prevalence rates reported in different studies and reviews vary considerably and provide no clear picture about sciatica prevalence.

METHODS

A literature search of all English language peer reviewed publications was conducted using Medline, EMBASE, and CINAHL for the years 1980-2006. Two reviewers extracted data on sciatica prevalence and definitions from the identified articles.

RESULTS

Of the papers retrieved, 23 were included in the review. Only 2 studies out of the 23 used clinical assessment for assessing sciatic symptoms, and definitions of sciatica varied widely. Sciatica prevalence from different studies ranged from 1.2% to 43%.

CONCLUSION

Sciatica prevalence estimates vary considerably between studies. This may be due to differences in definitions, methods of data collection and perhaps populations studied. Suggestions are made on how to improve accuracy of capturing sciatica in epidemiological studies.

Epidural neuroplasty versus physiotherapy to relieve pain in patients with sciatica: a prospective randomized blinded clinical trial

BACKGROUND

Epidural neuroplasty seems to be one of the promising minimally invasive techniques for adhesiolysis in patients with chronic sciatica with or without low back pain. However, because no data exist from randomized studies the aim was to investigate whether this procedure is superior to conservative treatment with physiotherapy.

METHODS

A total of 99 patients with chronic low back pain were enrolled in this study and randomly assigned into either a group with physiotherapy (n = 52) or a second group undergoing epidural neuroplasty (n = 47). Patients were assessed before and 3, 6, and 12 months after treatment by a blinded investigator.

RESULTS

After 3 months, the visual analog scale (VAS) score for back and leg pain was significantly reduced in the epidural neuroplasty group, and the need for pain medication was reduced in both groups. Furthermore, the VAS for back and leg pain as well as the Oswestry disability score were significantly reduced until 12 months after the procedure in contrast to the group that received conservative treatment.

CONCLUSIONS

Epidural neuroplasty results in significant alleviation of pain and functional disability in patients with chronic low back pain and sciatica based on disc protrusion/prolapse or failed back surgery on a short-term basis as well as at 12 months of follow-up.