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Kim KD, Ahadian F, Hassanzadeh H, Rivera J, Candido K, Gershon S, Patel A, Gupta PB, Miller AE, Formoso FJ, Fuerst T, Zucker E, Seo T, Watanabe J, Matsuyama Y, Chiba K, Macadaeg KE. A phase 3, randomized, double-blind, sham-controlled trial of SI-6603 (condoliase) in patients with radicular leg pain associated with lumbar disc herniation. Spine J 2024:S1529-9430(24)00936-7. [PMID: 39168360 DOI: 10.1016/j.spinee.2024.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 06/25/2024] [Accepted: 08/09/2024] [Indexed: 08/23/2024]
Abstract
BACKGROUND CONTEXT SI-6603 (condoliase) is a chemonucleolytic agent approved in Japan in 2018 for the treatment of lumbar disc herniation (LDH) associated with radicular leg pain. Condoliase, a mucopolysaccharidase with high substrate specificity for glycosaminoglycans (GAGs), offers a unique mechanism of action through the degradation of GAGs in the nucleus pulposus. As LDH management is currently limited to conservative approaches and surgical intervention, condoliase could offer a less invasive treatment option than surgery for patients with LDH. PURPOSE The Discover 6603 study (NCT03607838) evaluated the efficacy and safety of a single-dose injection of SI-6603 (condoliase) vs sham for the treatment of radicular leg pain associated with LDH. STUDY DESIGN/SETTING A randomized, double-blind, sham-controlled, phase 3 study conducted across 41 sites in the United States. PATIENT SAMPLE Male and female participants (N=352; aged 30-70 years) with contained posterolateral LDH and unilateral radiculopathy/radicular leg pain for greater than 6 weeks. OUTCOME MEASURES The primary endpoint was the change from baseline (CFB) in average worst leg pain score at 13 weeks, assessed using the 100-mm visual analogue scale. Key secondary endpoints were CFB in average worst leg pain score at 52 weeks, herniation volume at 13 weeks, and Oswestry Disability Index (ODI) score at 13 weeks. Safety evaluations included adverse events (AEs) and imaging findings. METHODS Participants were randomized 1:1 to receive a single intradiscal injection of condoliase (1.25 units) or sham injection followed by 52 weeks of observation. The primary and key secondary endpoints were assessed using a mixed model for repeated measures (MMRM) analysis and a protocol-specified multiple imputation (MI) sensitivity analysis on the modified intention-to-treat (mITT) population. A prespecified serial gatekeeping algorithm was used for multiple comparisons. Safety endpoints included AEs, laboratory tests, vital signs, imaging (by X-ray and magnetic resonance imaging [MRI]), and occurrence of posttreatment lumbar surgery. RESULTS Of the 352 randomized participants, 341 constituted the mITT population (condoliase n=169; sham n=172) and the safety population (condoliase n=167; sham n=174). For the primary endpoint, the condoliase group showed significantly greater improvement in CFB in worst leg pain at Week 13 (least squares mean [LSM] CFB: -41.7) compared with sham injection (-34.2; LSM difference: -7.5; 95% confidence interval [CI]: -14.1, -0.9; p=.0263) based on the MMRM analysis. CFB in worst leg pain at Week 52 favored condoliase vs sham, but the difference was not statistically significant (p=.0558), which halted the serial gatekeeping testing algorithm and dictated that the CFB in herniation volume and ODI scores at Week 13 would be considered nonsignificant, regardless of their p-values. Treatment group differences in CFB in herniation volume and ODI score favored the condoliase group vs sham at all timepoints. The MI sensitivity analysis showed differences in CFB in worst leg pain at Week 13 (p=.0223) and Week 52 (p=.0433) in favor of the condoliase group. Treatment-emergent AEs (TEAEs) were more common in the condoliase group (≥1 TEAE: 71.9%; ≥1 treatment-related TEAE: 28.1%) compared with the sham group (≥1 TEAE: 60.3%; ≥1 treatment-related TEAE: 10.3%). Of the TEAEs, spinal MRI abnormalities and back pain occurred most frequently. No treatment-related serious AEs occurred. CONCLUSIONS Condoliase met its primary endpoint of significantly improving radicular leg pain at Week 13 and was generally well tolerated in patients with LDH. Chemonucleolysis with condoliase has the potential to provide a less invasive treatment option than surgery for those unresponsive to conservative treatment strategies.
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Affiliation(s)
- Kee D Kim
- Department of Neurological Surgery, University of California, Davis, Sacramento, CA, USA.
| | - Farshad Ahadian
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA
| | - Hamid Hassanzadeh
- Department of Orthopedic Surgery, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Jose Rivera
- Department of Anesthesiology & Pain Medicine, Tampa Pain Relief Centers, Tampa, FL, USA
| | - Kenneth Candido
- Department of Anesthesiology, Chicago Anesthesia Pain Specialists, Chicago, IL, USA
| | - Steven Gershon
- Department of Pain Management, Gershon Pain Specialists, Virginia Beach, VA, USA
| | - Anand Patel
- Department of Anesthesiology, Conquest Research, Winter Park, FL, USA
| | - Pragya B Gupta
- Department of Pain Management, Otrimed Clinical Research, Edgewood, KY, USA
| | - Alan E Miller
- Department of Pain Management, Coastal Spine & Pain Center, Fernandina Beach, FL, USA
| | - Ferdinand J Formoso
- Department of Acute and Chronic Pain, Coastal Spine & Pain Center, Jacksonville, FL, USA
| | - Thomas Fuerst
- Department of Musculoskeletal Medicine, Clario, San Mateo, CA, USA
| | - Evan Zucker
- Department of Biostatistics, Rho, Inc., Durham, NC, USA
| | - Takayuki Seo
- Clinical Development Department, Research & Development Division, Seikagaku Corporation, Tokyo, Japan
| | - Jun Watanabe
- Department of Drug Development, Seikagaku North America Corporation, Toronto, ON, Canada
| | - Yukihiro Matsuyama
- Department of Orthopedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Kazuhiro Chiba
- Department of Orthopedic Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Kevin E Macadaeg
- Department of Spinal Diagnostics and Therapeutics, Indiana Spine Group, Carmel, IN, USA
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Coker C, Park J, Jacobson RD. Neurologic Approach to Radiculopathy, Back Pain, and Neck Pain. Prim Care 2024; 51:345-358. [PMID: 38692779 DOI: 10.1016/j.pop.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Back pain and neck pain are common in clinical practice, but significant challenges and pitfalls exist in their diagnosis, treatment, and management. From the neurologic standpoint, cervical radiculopathy and lumbosacral radiculopathy are characterized by neck pain or back pain accompanied by sensory and motor symptoms in an arm or leg. The basic neurologic examination is vital, but testing like electromyography and MRI is often needed especially in cases that fail conservative management. Oral medications, injection-based therapies, physical therapy, and surgical evaluation all have a place in the comprehensive neurologic management of back and neck pain and associated radiculopathy.
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Affiliation(s)
- Canaan Coker
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison Street, Suite 1118, Chicago, IL 60612, USA
| | - Jade Park
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison Street, Suite 1118, Chicago, IL 60612, USA
| | - Ryan D Jacobson
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison Street, Suite 1118, Chicago, IL 60612, USA.
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HajAli T, Shmaisani A, Fares Y, Abou-Abbas L. Predictors of neuropathic pain and related functional disability in sciatica patients: a cross-sectional study. Int J Neurosci 2023; 133:1338-1345. [PMID: 35603462 DOI: 10.1080/00207454.2022.2079504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 05/12/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The aim of the present paper was to assess neuropathic pain and its predictors among patients with sciatica. In addition, we sought to investigate the predictors of functional disability in sciatica patients with neuropathic pain. METHODS A cross-sectional study was carried out on a sample of 100 sciatica patients aged 18 years and older with a radiating pain from the lower back down to the leg below the knee. Information about socio-demographic characteristics, duration of symptoms, being treated or not, type of treatment, side of sciatica, presence of back pain, leg pain occurrence, leg pain intensity, functional disability and pain catastrophizing were collected. RESULTS Of the total patients, 57% had neuropathic pain. Multivariable analysis showed that leg pain intensity was higher in the neuropathic pain group as compared to the non-neuropathic pain group. Also, patients with left sciatica were less likely to have neuropathic pain than patients with right sciatica. Patients with neuropathic pain having high levels of pain catastrophizing and being on bed rest for at least one week were at a higher risk of developing functional disability as compared to their counterparts. CONCLUSION Low levels of pain catastrophizing and less bed rest should be considered in interventions aimed at improving the functional ability for sciatica patients with neuropathic pain.
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Affiliation(s)
- Thuraya HajAli
- Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Ammar Shmaisani
- Neurosurgery Department, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Youssef Fares
- Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
- Neurosurgery Department, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Linda Abou-Abbas
- Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
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Favorable long-term health-related quality of life after surgery for lumbar disc herniation in young adult patients. Acta Neurochir (Wien) 2023; 165:797-805. [PMID: 36805802 PMCID: PMC10006264 DOI: 10.1007/s00701-023-05522-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/25/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Lumbar disc herniation is often managed conservatively; nevertheless, surgical intervention can be required. Majority of patients experience a drastic relief of symptoms after surgery, but previous studies have reported that their health-related quality of life remains inferior compared to the general population for several years. There may be a major cumulative loss of health-related quality of life for young patients as they have long expected life ahead of them. METHODS A total of 526 eligible adult patients under the age of 40 underwent surgery for lumbar disc herniation from 1990 to 2005. Patients' baseline characteristics were acquired by chart review to confirm eligibility to the study. Follow-up quality of life data was acquired by sending patients EQ-5D questionnaire at median 18 years after index surgery, and those 316 patients responding to the questionnaire (60%) were included in the study. Propensity score matching was utilized to match every study patient with two general population sample participants from a large Finnish population health study. Primary objective was to compare the quality of life to that of the control population. Secondary objective was to explore which patient characteristics lead to inferior outcome. RESULTS The mean EQ-index for the patient cohort was 0.86, while it was 0.84 for the age and gender-matched general population sample (difference 0.02, 95% CI - 0.0004 to 0.049). Within the patient cohort, an increasing number of lifetime lumbar surgeries was associated with progressively deteriorating EQ-index scores (p = 0.049) and longer duration of symptoms prior to the surgery correlated with lower score (p = 0.013). CONCLUSION Patients who underwent surgery for lumbar disc herniation nearly two decades ago reported quality of life comparable to the age and gender-matched general population. However, patients who had undergone numerous lumbar surgeries had significantly worse outcome. Therefore, possible ways to prevent cumulation of lumbar surgeries could improve long-term health-related quality of life.
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van Loon OR, van Loon AJT. Rest is essential for effective therapies, and so it is for preparing a manuscript. Complement Ther Med 2023; 72:102921. [PMID: 36693510 DOI: 10.1016/j.ctim.2023.102921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/15/2023] [Accepted: 01/20/2023] [Indexed: 01/22/2023] Open
Abstract
Numerous medical articles are commented upon. This suggests that their scientific quality is insufficient. This need not be the case, however: most comments regard the presentation of the data, the conclusions or lacking information in the discussion. Such flaws can commonly be attributed to either too much haste in writing the manuscript, or insufficient time between finishing the manuscript and submission; this last problem seems the most common cause, as it deprives the author from reading his own text critically and with an open mind. The solution for this problem is simple: after having finished a manuscript, it should be laid aside for at least a week, after which the author should read it with the eyes of a reader, not the eyes of an author. Critical, open-minded reading after rest helps increase the quality of the resulting manuscript, just like rest helps a patient during most therapies.
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Affiliation(s)
- Olaf R van Loon
- Privat Klinik im Park, Therapy Department, Badstrasse 50, CH-5116 Schinznach-Bad, Switzerland.
| | - A J Tom van Loon
- College of Earth Science and Engineering, Shandong University of Science and Technology, Qingdao 266590, Shandong, China.
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Corrêa LA, Bittencourt JV, Mainenti Pagnez MA, Mathieson S, Saragiotto BT, Telles GF, Meziat-Filho N, Calazans Nogueira LA. Neural management plus advice to stay active on clinical measures and sciatic neurodynamic for patients with chronic sciatica: Study protocol for a controlled randomised clinical trial. PLoS One 2022; 17:e0263152. [PMID: 35120149 PMCID: PMC8815873 DOI: 10.1371/journal.pone.0263152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/28/2021] [Indexed: 12/04/2022] Open
Abstract
Advice to stay active is the primary management strategy for sciatica. Other conservative treatments such as neural management techniques may also contribute to sciatica recovery, but currently, the effects have not been robustly assessed. Thus, the aim of this study is to compare the effects of adding neural management to advice to stay active versus advice to stay active alone in improving pain intensity and functional limitation. Secondarily, to compare the effects of the experimental intervention in the sciatic neurodynamic, pain modulation, and psychosocial factors. A parallel-group, controlled, examiner-blinded superiority clinical trial randomised at a 1:1 allocation will be conducted in 210 participants with chronic sciatica. Patients will be recruited from outpatient physiotherapy clinics and community advertisements. The experimental group will receive neural mobilisation techniques and soft tissue mobilisation techniques for 30 minutes per session, 10 weekly sessions, plus advice to stay active on their activities of daily living, information on physical activity, imaging tests, and sciatica for 5 biweekly sessions lasting 25-30 minutes. The control group will receive advice to stay active only. The re-evaluation will be performed out after 5 weeks, 10 weeks, and 26 weeks after randomisation and primary endpoints will be pain intensity and functional limitation at 10 weeks. Secondary outcomes will include neuropathic symptoms, sciatic neurodynamic, pain modulation, and psychosocial factors. Adverse events and patient satisfaction will be assessed. Ethical approval has been granted from an Institutional Human Research Ethics Committee. Trial registration: Trial was prospectively registered in the Brazilian Registry of Clinical Trials (number: RBR-3db643c).
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Affiliation(s)
- Leticia Amaral Corrêa
- Rehabilitation Science Postgraduation Program, Augusto Motta University Centre (UNISUAM), Rio de Janeiro, Brazil
| | - Juliana Valentim Bittencourt
- Rehabilitation Science Postgraduation Program, Augusto Motta University Centre (UNISUAM), Rio de Janeiro, Brazil
| | - Maria Alice Mainenti Pagnez
- Rehabilitation Science Postgraduation Program, Augusto Motta University Centre (UNISUAM), Rio de Janeiro, Brazil
| | - Stephanie Mathieson
- Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | | | - Gustavo Felicio Telles
- Rehabilitation Science Postgraduation Program, Augusto Motta University Centre (UNISUAM), Rio de Janeiro, Brazil
| | - Ney Meziat-Filho
- Rehabilitation Science Postgraduation Program, Augusto Motta University Centre (UNISUAM), Rio de Janeiro, Brazil
| | - Leandro Alberto Calazans Nogueira
- Rehabilitation Science Postgraduation Program, Augusto Motta University Centre (UNISUAM), Rio de Janeiro, Brazil
- Physiotherapy Department, Federal Institute of Rio de Janeiro (IFRJ), Rio de Janeiro, Brazil
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7
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Huang Z, Chen J, Su Y, Guo M, Chen Y, Zhu Y, Nie G, Ke R, Chen H, Hu J. Impact of dyslipidemia on the severity of symptomatic lumbar spine degeneration: A retrospective clinical study. Front Nutr 2022; 9:1033375. [PMID: 36583215 PMCID: PMC9792470 DOI: 10.3389/fnut.2022.1033375] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/25/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Lumbar intervertebral disc degeneration (IVDD) is an important cause of low back pain or sciatica, and metabolic factors play an important role. However, little is known about the relationship of dyslipidemia to the risk of intervertebral disc degeneration (IVDD). This study aimed to assess the impact of serum lipid levels on the severity of lumbar disc degeneration and to investigate its association with endplate inflammation. METHODS We conducted a case retrospective study in which a total of 302 hospitalized Chinese patients were recruited, of whom 188 (112 males and 76 females; mean age: 51.66 years) were without underlying disease, while the remaining 114 patients (51 males and 63 females; mean age: 62.75 years) had underlying diseases. We examined fasting serum lipid levels for total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C). Magnetic resonance imaging (MRI) was used to determine endplate inflammation. Pfirrmann grading and Weishaupt grading were used to evaluate the severity of intervertebral disc degeneration and facet joint degeneration, respectively. RESULTS There was no difference in age, gender, and general BMI between the two groups (P > 0.05), but there were significantly high levels in TC, LDL-C, and LDL-C/HDL-C (P = 0.04, P = 0.013, P = 0.01, respectively). TG and HDL-C showed no significant difference (P = 0.064, P = 0.336, respectively). The multivariate logistic regression model showed that age was a risk factor for the occurrence of endplate inflammation. In the group without underlying diseases, age, but not other indicators, was a risk factor for the occurrence of endplate inflammation (P < 0.01), In the group with underlying diseases, none of the patient indicators was directly related to the occurrence of endplate inflammation (P > 0.05). A nonlinear machine learning model was used to measure the contribution of each factor to the disease outcome and to analyze the effect between the top three contributing factors and the outcome variables. In patients without underlying diseases, the top three factors contributing to the severity grading of intervertebral disc degeneration were age (32.9%), high-density lipoproteins (20.7%), and triglycerides (11.8%). For the severity grading of facet joint degeneration, the top three contributing factors were age (27.7%), high-density lipoproteins (19.4%), and triglycerides (14.6%). For patients with underlying diseases, the top three factors contributing to intervertebral disc degeneration were age (25.4%), BMI (15.3%), and low-density lipoprotein/high-density lipoprotein ratio (13.9%). In terms of degree classification for facet joint degeneration, the top three contributing factors were age (17.5%), BMI (17.2%), and total cholesterol (16.7%). CONCLUSION This study shows that age, high-density lipoprotein, and triglycerides affect the degree of degeneration in patients with symptomatic lumbar degeneration without underlying diseases. Age and BMI are two major factors affecting the severity of degeneration in patients with underlying diseases, and dyslipidemia is a secondary factor. However, there is no clear association between dyslipidemia and the occurrence of endplate inflammation in either group.
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Affiliation(s)
- Zhonglian Huang
- Department of Orthopaedics, The First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
- Orthopaedic Medical Research Center, The First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
| | - Jiechen Chen
- Department of Orthopaedics, The First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
- Orthopaedic Medical Research Center, The First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
| | - Yihong Su
- Department of Orthopaedics, The First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
- Orthopaedic Medical Research Center, The First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
| | - Muxin Guo
- Department of Orthopaedics, The First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
- Orthopaedic Medical Research Center, The First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
| | - Youbin Chen
- Department of Orthopaedics, The First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
- Orthopaedic Medical Research Center, The First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
| | - Yilin Zhu
- Department of Orthopaedics, The First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
- Orthopaedic Medical Research Center, The First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
| | - Guangshuai Nie
- Department of Orthopaedics, The First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
- Orthopaedic Medical Research Center, The First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
| | - Ruitian Ke
- Department of Radiology, The First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
| | - Hongjiang Chen
- Department of Orthopaedics, The First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
- Orthopaedic Medical Research Center, The First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
| | - Jun Hu
- Department of Orthopaedics, The First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
- Orthopaedic Medical Research Center, The First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
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Shirado O, Arai Y, Iguchi T, Imagama S, Kawakami M, Nikaido T, Ogata T, Orita S, Sakai D, Sato K, Takahata M, Takeshita K, Tsuji T. Formulation of Japanese Orthopaedic Association (JOA) clinical practice guideline for the management of low back pain- the revised 2019 edition. J Orthop Sci 2022; 27:3-30. [PMID: 34836746 DOI: 10.1016/j.jos.2021.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/12/2021] [Accepted: 06/22/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The latest clinical guidelines are mandatory for physicians to follow when practicing evidence-based medicine in the treatment of low back pain. Those guidelines should target not only Japanese board-certified orthopaedic surgeons, but also primary physicians, and they should be prepared based entirely on evidence-based medicine. The Japanese Orthopaedic Association Low Back Pain guideline committee decided to update the guideline and launched the formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline with the latest data of evidence-based medicine. METHODS The Japanese Orthopaedic Association Low Back Pain guideline formulation committee revised the previous guideline based on a method for preparing clinical guidelines in Japan proposed by Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014. Two key phrases, "body of evidence" and "benefit and harm balance" were focused on in the revised version. Background and clinical questions were determined, followed by literature search related to each question. Appropriate articles were selected from all the searched literature. Structured abstracts were prepared, and then meta-analyses were performed. The strength of both the body of evidence and the recommendation was decided by the committee members. RESULTS Nine background and nine clinical qvuestions were determined. For each clinical question, outcomes from the literature were collected and meta-analysis was performed. Answers and explanations were described for each clinical question, and the strength of the recommendation was decided. For background questions, the recommendations were described based on previous literature. CONCLUSIONS The 2019 clinical practice guideline for the management of low back pain was completed according to the latest evidence-based medicine. We strongly hope that this guideline serves as a benchmark for all physicians, as well as patients, in the management of low back pain.
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Affiliation(s)
- Osamu Shirado
- Department of Orthopaedic and Spinal Surgery, Aizu Medical Center (AMEC) at Fukushima Medical University, Japan.
| | - Yoshiyasu Arai
- Department of Orthopaedic Surgery, Saiseikai Kawaguchi General Hospital, Japan
| | - Tetsuhiro Iguchi
- Department of Orthopaedic Surgery, Saiseikai Hyogo Prefectural Hospital, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Japan
| | | | - Takuya Nikaido
- Department of Orthopaedic Surgery, Fukushima Medical University, Japan
| | | | - Sumihisa Orita
- Center for Frontier Medical Engineering (CFME), Department of Orthopaedic Surgery, Chiba University, Japan
| | - Daisuke Sakai
- Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, Japan
| | - Kimiaki Sato
- Department of Orthopaedic Surgery, Kurume University, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Japan
| | | | - Takashi Tsuji
- Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Japan
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Thomé C, Kuršumović A, Klassen PD, Bouma GJ, Bostelmann R, Martens F, Barth M, Arts M, Miller LE, Vajkoczy P, Hes R, Eustacchio S, Nanda D, Köhler HP, Brenke C, Flüh C, Van de Kelft E, Assaker R, Kienzler JC, Fandino J. Effectiveness of an Annular Closure Device to Prevent Recurrent Lumbar Disc Herniation: A Secondary Analysis With 5 Years of Follow-up. JAMA Netw Open 2021; 4:e2136809. [PMID: 34882183 PMCID: PMC8662371 DOI: 10.1001/jamanetworkopen.2021.36809] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
IMPORTANCE Patients with large annular defects following lumbar microdiscectomy for disc herniation are at increased risk for symptomatic recurrence and reoperation. OBJECTIVE To determine whether a bone-anchored annular closure device in addition to lumbar microdiscectomy resulted in lower reherniation and reoperation rates vs lumbar microdiscectomy alone. DESIGN, SETTING, AND PARTICIPANTS This secondary analysis of a multicenter randomized clinical trial reports 5-year follow-up for enrolled patients between December 2010 and October 2014 at 21 clinical sites. Patients in this study had a large annular defect (6-10 mm width) following lumbar microdiscectomy for treatment of lumbar disc herniation. Statistical analysis was performed from November to December 2020. INTERVENTIONS Lumbar microdiscectomy with additional bone-anchored annular closure device (device group) or lumbar microdiscectomy only (control group). MAIN OUTCOMES AND MEASURES The incidence of symptomatic reherniation, reoperation, and adverse events as well as changes in leg pain, Oswestry Disability Index, and health-related quality of life when comparing the device and control groups over 5 years of follow-up. RESULTS Among 554 randomized participants (mean [SD] age: 43 [11] years; 327 [59%] were men), 550 were included in the modified intent-to-treat efficacy population (device group: n = 272; 270 [99%] were White); control group: n = 278; 273 [98%] were White) and 550 were included in the as-treated safety population (device group: n = 267; control group: n = 283). The risk of symptomatic reherniation (18.8% [SE, 2.5%] vs 31.6% [SE, 2.9%]; P < .001) and reoperation (16.0% [SE, 2.3%] vs 22.6% [SE, 2.6%]; P = .03) was lower in the device group. There were 53 reoperations in 40 patients in the device group and 82 reoperations in 58 patients in the control group. Scores for leg pain severity, Oswestry Disability Index, and health-related quality of life significantly improved over 5 years of follow-up with no clinically relevant differences between groups. The frequency of serious adverse events was comparable between the treatment groups. Serious adverse events associated with the device or procedure were less frequent in the device group (12.0% vs 20.5%; difference, -8.5%; 95% CI, -14.6% to -2.3%; P = .008). CONCLUSIONS AND RELEVANCE In patients who are at high risk of recurrent herniation following lumbar microdiscectomy owing to a large defect in the annulus fibrosus, this study's findings suggest that annular closure with a bone-anchored implant lowers the risk of symptomatic recurrence and reoperation over 5 years of follow-up. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01283438.
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Affiliation(s)
- Claudius Thomé
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | - Adisa Kuršumović
- Department of Neurosurgery, Donauisar Klinikum Deggendorf, Deggendorf, Germany
| | | | - Gerrit J. Bouma
- Department of Neurosurgery, OLVG-West and Academic Medical Center, Amsterdam, the Netherlands
| | - Richard Bostelmann
- Department of Neurosurgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | | | - Martin Barth
- Department of Neurosurgery, University Hospital Bochum, Bochum, Germany
| | - Mark Arts
- Department of Neurosurgery, HMC Westeinde, Den Hague, the Netherlands
| | | | - Peter Vajkoczy
- Department of Neurosurgery, Charité Universitätsmedizin, Berlin, Germany
| | - Robert Hes
- Department of Neurosurgery, AZ Klina, Brasschaat, Belgium
| | | | - Dharmin Nanda
- Department of Neurosurgery, Isala Klinieken, Zwolle, the Netherlands
| | - Hans-Peter Köhler
- Department of Neurosurgery, Asklepios Westklinikum Hamburg, Hamburg, Germany
| | | | - Charlotte Flüh
- Department of Neurosurgery, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Erik Van de Kelft
- Department of Neurosurgery, AZ Nikolaas, Sint-Niklaas, Belgium & Faculty of Medicine and Health Sciences, Antwerp University, Wilrijk, Belgium
| | - Richard Assaker
- Department of Neurosurgery, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | | | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
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Knezevic NN, Candido KD, Vlaeyen JWS, Van Zundert J, Cohen SP. Low back pain. Lancet 2021; 398:78-92. [PMID: 34115979 DOI: 10.1016/s0140-6736(21)00733-9] [Citation(s) in RCA: 431] [Impact Index Per Article: 143.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 12/23/2020] [Accepted: 02/16/2021] [Indexed: 12/31/2022]
Abstract
Low back pain covers a spectrum of different types of pain (eg, nociceptive, neuropathic and nociplastic, or non-specific) that frequently overlap. The elements comprising the lumbar spine (eg, soft tissue, vertebrae, zygapophyseal and sacroiliac joints, intervertebral discs, and neurovascular structures) are prone to different stressors, and each of these, alone or in combination, can contribute to low back pain. Due to numerous factors related to low back pain, and the low specificity of imaging and diagnostic injections, diagnostic methods for this condition continue to be a subject of controversy. The biopsychosocial model posits low back pain to be a dynamic interaction between social, psychological, and biological factors that can both predispose to and result from injury, and should be considered when devising interdisciplinary treatment plans. Prevention of low back pain is recognised as a pivotal challenge in high-risk populations to help tackle high health-care costs related to therapy and rehabilitation. To a large extent, therapy depends on pain classification, and usually starts with self-care and pharmacotherapy in combination with non-pharmacological methods, such as physical therapies and psychological treatments in appropriate patients. For refractory low back pain, a wide range of non-surgical (eg, epidural steroid injections and spinal cord stimulation for neuropathic pain, and radiofrequency ablation and intra-articular steroid injections for mechanical pain) and surgical (eg, decompression for neuropathic pain, disc replacement, and fusion for mechanical causes) treatment options are available in carefully selected patients. Most treatment options address only single, solitary causes and given the complex nature of low back pain, a multimodal interdisciplinary approach is necessary. Although globally recognised as an important health and socioeconomic challenge with an expected increase in prevalence, low back pain continues to have tremendous potential for improvement in both diagnostic and therapeutic aspects. Future research on low back pain should focus on improving the accuracy and objectivity of diagnostic assessments, and devising treatment algorithms that consider unique biological, psychological, and social factors. High-quality comparative-effectiveness and randomised controlled trials with longer follow-up periods that aim to establish the efficacy and cost-effectiveness of low back pain management are warranted.
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Affiliation(s)
- Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA; Department of Anesthesiology, University of Illinois, Chicago, IL, USA; Department of Surgery, University of Illinois, Chicago, IL, USA.
| | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA; Department of Anesthesiology, University of Illinois, Chicago, IL, USA; Department of Surgery, University of Illinois, Chicago, IL, USA
| | - Johan W S Vlaeyen
- Research Group Health Psychology, University of Leuven, Leuven, Belgium; Research Group Experimental Health Psychology, Maastricht University, Maastricht, Netherlands; TRACE Center for Translational Health Research, KU, Leuven-Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Jan Van Zundert
- Department of Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium; Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Steven P Cohen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Neurology, Physical Medicine and Rehabilitation, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Psychiatry and Behavioral Sciences, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Department of Physical Medicine and Rehabilitation and Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
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11
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Zhang N, Wang LQ, Li JL, Su XT, Yu FT, Shi GX, Yang JW, Liu CZ. The Management of Sciatica by Acupuncture: An Expert Consensus Using the Improved Delphi Survey. J Pain Res 2021; 14:13-22. [PMID: 33447076 PMCID: PMC7802920 DOI: 10.2147/jpr.s280404] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/26/2020] [Indexed: 12/15/2022] Open
Abstract
Objective Acupuncture therapy is an effective non-drug therapy for sciatica, but it has not yet formed an effective treatment strategy and recommendations. Our objective was to establish an expert consensus on acupuncture treatment of sciatica for clinical guidance based on the improved Delphi survey. Methods A group of 80 clinical specialists was invited to participate in two rounds of semi-open clinical issue investigation. At the same time, the PubMed, Embase, and Cochrane Library databases were searched for systematic reviews on acupuncture treatment of sciatica, and the quality of evidence was evaluated. Then the three-round Delphi survey was undertaken with 30 experts based on the clinical issue investigation and systematic reviews. Results In round 1 of the Delphi survey, the experts evaluated 17 items identified from the results of the clinical investigation and literature review. The criterion for achieving consensus was a threshold of 80% agreement. After the three-round Delphi survey, 16 items (94.12%) achieved consensus, including 5 domains: the principle of acupuncture treatment for sciatica; the “dose” of acupuncture; the clinical effects of acupuncture; the adverse effects, and others. Conclusion This Delphi survey achieved an expert consensus on key items in the management of sciatica for acupuncture, which provides the current opinions in China. We trust that these treatment recommendations may facilitate their implementation in the future.
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Affiliation(s)
- Na Zhang
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, People's Republic of China.,School of Acupuncture-Moxibustion and Tuina, Shandong University of Chinese Medicine, Shandong, People's Republic of China
| | - Li-Qiong Wang
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, People's Republic of China
| | - Jin-Ling Li
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, People's Republic of China
| | - Xin-Tong Su
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, People's Republic of China
| | - Fang-Ting Yu
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, People's Republic of China
| | - Guang-Xia Shi
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, People's Republic of China
| | - Jing-Wen Yang
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, People's Republic of China
| | - Cun-Zhi Liu
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, People's Republic of China
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12
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Foster NE, Konstantinou K, Lewis M, Ogollah R, Saunders B, Kigozi J, Jowett S, Bartlam B, Artus M, Hill JC, Hughes G, Mallen CD, Hay EM, van der Windt DA, Robinson M, Dunn KM. Stratified versus usual care for the management of primary care patients with sciatica: the SCOPiC RCT. Health Technol Assess 2020; 24:1-130. [PMID: 33043881 DOI: 10.3310/hta24490] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Sciatica has a substantial impact on patients and society. Current care is 'stepped', comprising an initial period of simple measures of advice and analgesia, for most patients, commonly followed by physiotherapy, and then by more intensive interventions if symptoms fail to resolve. No study has yet tested a model of stratified care in which patients are subgrouped and matched to different care pathways based on their prognosis and clinical characteristics. OBJECTIVES The objectives were to investigate the clinical effectiveness and cost-effectiveness of a stratified care model compared with usual, non-stratified care. DESIGN This was a two-parallel group, multicentre, pragmatic, 1 : 1 randomised controlled trial. SETTING Participants were recruited from primary care (42 general practices) in North Staffordshire, North Shropshire/Wales and Cheshire in the UK. PARTICIPANTS Eligible patients were aged ≥ 18 years, had suspected sciatica, had access to a mobile phone/landline, were not pregnant, were not receiving treatment for the same problem and had not had previous spinal surgery. INTERVENTIONS In stratified care, a combination of prognostic and clinical criteria associated with referral to spinal specialist services was used to allocate patients to one of three groups for matched care pathways. Group 1 received advice and up to two sessions of physiotherapy, group 2 received up to six sessions of physiotherapy, and group 3 was fast-tracked to magnetic resonance imaging and spinal specialist opinion. Usual care was based on the stepped-care approach without the use of any stratification tools/algorithms. Patients were randomised using a remote web-based randomisation service. MAIN OUTCOME MEASURES The primary outcome was time to first resolution of sciatica symptoms (six point ordinal scale, collected via text messages). Secondary outcomes (at 4 and 12 months) included pain, function, psychological health, days lost from work, work productivity, satisfaction with care and health-care use. A cost-utility analysis was undertaken over 12 months. A qualitative study explored patients' and clinicians' views of the fast-track care pathway to a spinal specialist. RESULTS A total of 476 patients were randomised (238 in each arm). For the primary outcome, the overall response rate was 89.3% (88.3% and 90.3% in the stratified and usual care arms, respectively). Relief from symptoms was slightly faster (2 weeks median difference) in the stratified care arm, but this difference was not statistically significant (hazard ratio 1.14, 95% confidence interval 0.89 to 1.46; p = 0.288). On average, participants in both arms reported good improvement from baseline, on most outcomes, over time. Following the assessment at the research clinic, most participants in the usual care arm were referred to physiotherapy. CONCLUSIONS The stratified care model tested in this trial was not more clinically effective than usual care, and was not likely to be a cost-effective option. The fast-track pathway was felt to be acceptable to both patients and clinicians; however, clinicians expressed reluctance to consider invasive procedures if symptoms were of short duration. LIMITATIONS Participants in the usual care arm, on average, reported good outcomes, making it challenging to demonstrate superiority of stratified care. The performance of the algorithm used to allocate patients to treatment pathways may have influenced results. FUTURE WORK Other approaches to stratified care may provide superior outcomes for sciatica. TRIAL REGISTRATION Current Controlled Trials ISRCTN75449581. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 49. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Nadine E Foster
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, UK.,Keele Clinical Trials Unit, Keele University, Keele, UK
| | - Kika Konstantinou
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, UK.,Haywood Hospital, Midlands Partnership Foundation NHS Trust, Stoke-on-Trent, UK
| | - Martyn Lewis
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, UK.,Keele Clinical Trials Unit, Keele University, Keele, UK
| | - Reuben Ogollah
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, UK.,Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Benjamin Saunders
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, UK
| | - Jesse Kigozi
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Sue Jowett
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, UK.,Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Bernadette Bartlam
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, UK.,Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Majid Artus
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, UK
| | - Jonathan C Hill
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, UK
| | - Gemma Hughes
- Keele Clinical Trials Unit, Keele University, Keele, UK
| | - Christian D Mallen
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, UK
| | - Elaine M Hay
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, UK
| | - Danielle A van der Windt
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, UK
| | | | - Kate M Dunn
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, UK
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13
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Moore SA, Tipold A, Olby NJ, Stein V, Granger N. Current Approaches to the Management of Acute Thoracolumbar Disc Extrusion in Dogs. Front Vet Sci 2020; 7:610. [PMID: 33117847 PMCID: PMC7521156 DOI: 10.3389/fvets.2020.00610] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/28/2020] [Indexed: 12/15/2022] Open
Abstract
Intervertebral disc extrusion (IVDE) is one of the most common neurologic problems encountered in veterinary clinical practice. The purpose of this manuscript is to provide an overview of the literature related to treatment of acute canine thoracolumbar IVDE to help construct a framework for standard care of acute canine thoracolumbar IVDE where sufficient evidence exists and to highlight opportunities for future prospective veterinary clinical research useful to strengthen care recommendations in areas where evidence is low or non-existent. While there exist a number of gaps in the veterinary literature with respect to standards of care for dogs with acute thoracolumbar IVDE, recommendations for standard care can be made in some areas, particularly with respect to surgical decompression where the currently available evidence supports that surgery should be recommended for dogs with nonambulatory paraparesis or worse. While additional information is needed about the influence on timing of decompression on outcome in dogs that are deep pain negative for longer than 48 h duration, there is no evidence to support treatment of the 48 h time point as a cut off beyond which it becomes impossible for dogs to achieve locomotor recovery. Surgical decompression is best accomplished by either hemilaminectomy or mini-hemilaminectomy and fenestration of, at a minimum, the acutely ruptured disc. Adjacent discs easily accessed by way of the same approach should be considered for fenestration given the evidence that this substantially reduces future herniation at fenestrated sites. Currently available neuroprotective strategies such as high does MPSS and PEG are not recommended due to lack of demonstrated treatment effect in randomized controlled trials, although the role of anti-inflammatory steroids as a protective strategy against progressive myelomalacia and the question of whether anti-inflammatory steroids or NSAIDs provide superior medical therapy require further evaluation.
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Affiliation(s)
- Sarah A Moore
- Department of Veterinary Clinical Sciences, The Ohio State University College of Veterinary Medicine, Columbus, OH, United States
| | - Andrea Tipold
- Department Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hanover, Germany
| | - Natasha J Olby
- Department of Clinical Sciences, North Carolina State University College of Veterinary Medicine, Raleigh, NC, United States
| | - Veronica Stein
- Division of Clinical Neurology, Department for Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Nicolas Granger
- The Royal Veterinary College, University of London, Hatfield, United Kingdom.,CVS Referrals, Bristol Veterinary Specialists at Highcroft, Bristol, United Kingdom
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14
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Campos-Daziano M. HERNIA DEL DISCO INTERVETEBRAL LUMBAR: REVISIÓN NARRATIVA DE CLÍNICA Y MANEJO. REVISTA MÉDICA CLÍNICA LAS CONDES 2020. [DOI: 10.1016/j.rmclc.2020.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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15
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Ostafiński K, Świątnicki W, Szymański J, Szymańska A, Nowosławska E, Zakrzewski K, Komuński P. Predicting conservative treatment failure in patients with lumbar disc herniation. Single center, case-control study. Clin Neurol Neurosurg 2020; 193:105867. [PMID: 32389892 DOI: 10.1016/j.clineuro.2020.105867] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/17/2020] [Accepted: 04/19/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The aim of this study was to identify independent predictors of conservative treatment failure in patients presenting due to lumbar disc herniation-associated low back pain and sciatica. PATIENTS AND METHODS This is a single institution, case-control study including 240 patients that were selected for microsurgical or conservative treatment due to lumbar disc herniation in a 2,5-year period. Bivariate and multivariate analyses were performed in order to identify independent predictors among demographic, clinical and radiographic factors. RESULTS Statistically significant differences were observed between conservatively and surgically managed groups in bivariate analysis. Logistic regression models further revealed that leg paresthesia (p = 0,003; OR = 5,136) and percentage of spinal canal stenosis ratio (p < 0,001; OR = 1,055) had the strongest, independent correlation with conservative treatment failure in our cohort. Back-to-leg ratio did not reach statistical significance although it proved a strong correlation in bivariate analysis (p < 0,001, Cramér's V = 0,53). CONCLUSION Increasing % canal compromise ratio (cut-off value 23%) and co-occurrence of leg paresthesia were the most important risk factors for surgery in our series of patients.
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Affiliation(s)
- Krzysztof Ostafiński
- Neurological Rehabilitation Unit, Maria Skłodowska-Curie Hospital, District of Łódź-North, Zgierz, Poland
| | - Wojciech Świątnicki
- Department of Neurosurgery, Maria Skłodowska-Curie Hospital, District of Łódź-North, Zgierz, Poland.
| | | | - Anna Szymańska
- Faculty of Economics and Sociology, University of Lodz, Poland
| | - Emilia Nowosławska
- Department of Pediatric Neurosurgery, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Krzysztof Zakrzewski
- Department of Pediatric Neurosurgery, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Piotr Komuński
- Department of Neurosurgery, Maria Skłodowska-Curie Hospital, District of Łódź-North, Zgierz, Poland
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16
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Miller LE, Allen RT, Duhon B, Radcliff KE. Expert review with meta-analysis of randomized and nonrandomized controlled studies of Barricaid annular closure in patients at high risk for lumbar disc reherniation. Expert Rev Med Devices 2020; 17:461-469. [PMID: 32237917 DOI: 10.1080/17434440.2020.1745061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Introduction: Patients with lumbar disc herniation and associated sciatica are often referred for lumbar discectomy. The surgical defect in the annulus fibrosus is typically left unrepaired after lumbar discectomy. Patients with large postsurgical annular defects (≥6 mm width) have a higher risk of symptom recurrence and reoperation compared to those with small defects. In these high-risk patients, a treatment gap exists due to the lack of effective treatments for durable annulus fibrosus repair.Areas covered: This article highlights the therapeutic need and summarizes the clinical results of a bone-anchored annular closure device (Barricaid) that was designed to fill the treatment gap in patients with large postsurgical annular defects. Clinical results were summarized by means of a systematic review with meta-analysis of two randomized and two nonrandomized controlled studies.Expert opinion: Professional societal recommendations and clinical study results support the adoption of bone-anchored annular closure for use in properly selected patients undergoing lumbar discectomy who are at high-risk for reherniation due to a large postsurgical defect in the annulus fibrosus. The risks of symptomatic reherniation and reoperation are approximately 50% lower in patients treated with lumbar discectomy and the Barricaid device compared to lumbar discectomy only, representing a clinically effective treatment strategy.
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Affiliation(s)
| | - R Todd Allen
- Department of Orthopaedic Surgery, UC San Diego Health System, San Diego, CA, USA
| | - Brad Duhon
- Department of Neurosurgery, University of Colorado, Lone Tree, CO, USA
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17
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Affiliation(s)
- Raymond Wjg Ostelo
- Department of Health Sciences, Faculty of Science, Vrije University Amsterdam, the Netherlands; Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences Research Institute, the Netherlands.
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18
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19
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Oosterhuis T, Smaardijk VR, Kuijer PPF, Langendam MW, Frings-Dresen MHW, Hoving JL. Systematic review of prognostic factors for work participation in patients with sciatica. Occup Environ Med 2019; 76:772-779. [PMID: 31296665 PMCID: PMC6817989 DOI: 10.1136/oemed-2019-105797] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/28/2019] [Accepted: 06/06/2019] [Indexed: 12/05/2022]
Abstract
Sciatica impacts on the ability to work and may lead to a reduced return to work. This study reviewed and summarised prognostic factors of work participation in patients who received conservative or surgical treatment for clinically diagnosed sciatica. We searched MEDLINE, CINAHL, EMBASE and PsycINFO until January 2018. Cohort studies, using a measure of work participation as outcome, were included. Two independent reviewers performed study inclusion and used the Quality In Prognosis Studies tool for risk of bias assessment and GRADE to rate the quality of the evidence. Based on seven studies describing six cohorts (n=1408 patients) that assessed 21 potential prognostic factors, favourable factors for return to work (follow-up ranging from 3 months to 10 years) included younger age, better general health, less low back pain or sciatica bothersomeness, better physical function, negative straight leg raise-test, physician expecting surgery to be beneficial, better pain coping, less depression and mental stress, less fear of movement and low physical work load. Study results could not be pooled. Using GRADE, the quality of the evidence ranged from moderate to very low, with downgrading mainly for a high risk of bias and imprecision. Several prognostic factors like pain, disability and psychological factors were identified and reviewed, and these could be targeted using additional interventions to optimise return to work. PROSPERO registration number: CRD42016042497.
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Affiliation(s)
- Teddy Oosterhuis
- Coronel Institute of Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Veerle R Smaardijk
- Coronel Institute of Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - P Paul Fm Kuijer
- Coronel Institute of Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Miranda W Langendam
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Monique H W Frings-Dresen
- Coronel Institute of Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Jan L Hoving
- Coronel Institute of Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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20
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Nanda D, Arts MP, Miller LE, Köhler HP, Perrin JM, Flüh C, Vajkoczy P. Annular closure device lowers reoperation risk 4 years after lumbar discectomy. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2019; 12:327-335. [PMID: 31564999 PMCID: PMC6732571 DOI: 10.2147/mder.s220151] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 08/17/2019] [Indexed: 01/22/2023] Open
Abstract
Objective To determine whether implanting an annular closure device (ACD) following a lumbar discectomy procedure in patients with large defects in the annulus fibrosus lowers the risk of reoperation after 4 years. Methods In a multicenter randomized trial, patients with large annular defects following single-level lumbar discectomy were intraoperatively randomized to additionally receive an ACD or no treatment (Controls). Clinical and imaging follow-up were performed at routine intervals over 4 years of follow-up. Main outcomes included reoperations at the treated lumbar level, leg pain scores on a visual analog scale, Oswestry Disability Index (ODI), and Physical Component Summary (PCS) and Mental Component Summary (MCS) scores from the SF-36 questionnaire. Results Among 550 patients (ACD 272, Control 278), the risk of reoperation over 4 years was 14.4% with ACD and 21.1% with Controls (P=0.03). The reduction in reoperation risk with ACD was not significantly influenced by patient age (P=0.51), sex (P=0.34), body mass index (P=0.21), smoking status (P=0.85), level of herniation (P=0.26), leg pain severity at baseline (P=0.90), or ODI at baseline (P=0.54). All patient-reported outcomes improved in each group from baseline to 4 years (all P<0.001). The percentage of patients who achieved the minimal clinically important difference without a reoperation was proportionally higher in the ACD group compared to Controls for leg pain (P=0.07), ODI (P=0.10), PCS (P=0.02), and MCS (P=0.06). Conclusion The addition of a bone-anchored ACD following lumbar discectomy in patients with large post-surgical annular defects reduces the risk of reoperation and provides better long-term pain and disability relief over 4 years compared to lumbar discectomy only.
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Affiliation(s)
- Dharmin Nanda
- Department of Neurosurgery, Isala Klinieken, Zwolle, the Netherlands
| | - Mark P Arts
- Department of Neurosurgery, Haaglanden Medical Center Westeinde, The Hague, the Netherlands
| | | | - Hans-Peter Köhler
- Department of Neurosurgery, Asklepios Westklinikum Hamburg, Hamburg, Germany
| | - Jason M Perrin
- Department of Neurosurgery, University Clinic Mannheim, Mannheim, Germany
| | - Charlotte Flüh
- Department of Neurosurgery, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité Universitätsmedizin, Berlin, Germany
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Lee JH, Choi KH, Kang S, Kim DH, Kim DH, Kim BR, Kim W, Kim JH, Do KH, Do JG, Ryu JS, Min K, Bahk SG, Park YH, Bang HJ, Shin KH, Yang S, Yang HS, Yoo SD, Yoo JS, Yoon KJ, Yoon SJ, Lee GJ, Lee SY, Lee SC, Lee SY, Lee IS, Lee JS, Lee CH, Lim JY, Han JY, Han SH, Sung DH, Cho KH, Kim SY, Kim HJ, Ju W. Nonsurgical treatments for patients with radicular pain from lumbosacral disc herniation. Spine J 2019; 19:1478-1489. [PMID: 31201860 DOI: 10.1016/j.spinee.2019.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 06/02/2019] [Accepted: 06/04/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbosacral disc herniation (LDH) is one of the most frequent musculoskeletal diseases causative of sick leave in the workplace and morbidity in daily activities. Nonsurgical managements are considered as first line treatment before surgical treatment. PURPOSE This clinical practice guideline (CPG) is intended to provide physicians who treat patients diagnosed with LDH with a guideline supported by scientific evidence to assist in decision-making for appropriate and reasonable treatments. STUDY DESIGN/SETTING A systematic review. PATIENT SAMPLE Studies of human subjects written in Korean or English that met the following criteria were selected: patients aged ≥18 years, clinical presentation of low back and radicular leg pain, diagnosis of LDH on radiological evaluation including computed tomography or magnetic resonance imaging. OUTCOMES MEASURES Pain and functional evaluation scales such as visual analogue scale, numeric rating scale, and Oswestry disability index METHODS: The MEDLINE (PubMed), EMBASE, Cochrane Review, and KoreaMed databases were searched for articles regarding non-surgical treatments for LDH published up to July 2017. Of the studies fulfilling these criteria, those investigating clinical results after non-surgical treatment including physical and behavioral therapy, medication, and interventional treatment in terms of pain control and functional improvements were chosen for this study. RESULTS Nonsurgical treatments were determined to be clinically effective with regards to pain reduction and functional improvement in patients with LDH. Nevertheless, the evidence level was generally not evaluated as high degree, which might be attributed to the paucity of well-designed randomized controlled trials. Exercise and traction were strongly recommended despite moderate level of evidence. Epidural injection was strongly recommended with high degree of evidence and transforaminal approach was more strongly recommended than caudal approach. CONCLUSIONS This CPG provides new and updated evidence-based recommendations for treatment of the patients with LDH, which suggested that, despite an absence of high degrees of evidence level, non-surgical treatments were clinically effective.
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Affiliation(s)
- Jung Hwan Lee
- Namdarun Rehabilitation Clinic, Yongin-si, Gyeongg-do, South korea
| | - Kyoung Hyo Choi
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
| | - Seok Kang
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, South Korea
| | - Dong Hwan Kim
- Department of Physical and Rehabilitation Medicine, College of Medicine, Kyung Hee University Hospital, South Korea
| | - Du Hwan Kim
- Department of Physical and Rehabilitation Medicine, Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, South Korea
| | - Bo Ryun Kim
- Department of Rehabilitation Medicine, School of Medicine, Jeju National University, Jeju, South Korea
| | - Won Kim
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jung Hwan Kim
- Rehabilitation Hospital and Research Institute, National Rehabilitation Center, Seoul, South Korea
| | - Kyung Hee Do
- Department of Physical Medicine and Rehabilitation, Veterans Health Service Medical Center, Seoul, South Korea
| | - Jong Geol Do
- Department of Physical and Rehabilitation Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ju Seok Ryu
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundnang Hospital, Seoul, South Korea
| | - Kyunghoon Min
- Department of Rehabilitation Medicine, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Sung Gin Bahk
- Department of Physical Medicine & Rehabilitation, Seocho Se Barun Hospital, Seoul, South Korea
| | - Yun Hee Park
- Department of Physical Medicine and Rehabilitation, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Heui Je Bang
- Department of Rehabilitation Medicine, College of Medicine, Chungbuk National University, Cheongju, South Korea
| | - Kyoung-Ho Shin
- Heal & Tun Rehabilitation Medicine Clinic, Seongnam-si, Gyeonggi-do, South Korea
| | - Seoyon Yang
- Department of Physical and Rehabilitation Medicine, Seoul Hyundai Hospital, Seoul, South Korea
| | - Hee Seung Yang
- Department of Physical and Rehabilitation Medicine, Veterans medical center, Seoul, South Korea
| | - Seung Don Yoo
- Department of Physical and Rehabilitation Medicine, Kyung Hee university, College of Medicine, Seoul, South Korea
| | - Ji Sung Yoo
- Department of Rehabilitation Medicine, Research Institute and Hospital, National Cancer Center, South Korea
| | - Kyung Jae Yoon
- Department of Physical and Rehabilitation Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Se Jin Yoon
- Department of Physical and Rehabilitation Medicine, Danam Rehabilitation Hospital, South Korea
| | - Goo Joo Lee
- Department of Rehabilitation Medicine, Chungbuk National University Hospital, Cheongju, South Korea
| | - Sang Yoon Lee
- Department of Rehabilitation Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Sang Chul Lee
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung Yeol Lee
- Department of Physical Medicine and Rehabilitation, College of Medicine, Soonchunhyang University Hospital, Seoul, South Korea
| | - In-Sik Lee
- Department of Rehabilitation Medicine, Konkuk University School of Medicine and Konkuk University Medical Center, Seoul, South Korea
| | - Jung-Soo Lee
- Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Chang-Hyung Lee
- Department of Physical and Rehabilitation Medicine, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Busan, South Korea
| | - Jae-Young Lim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jae-Young Han
- Department of Physical and Rehabilitation Medicine, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Seung Hoon Han
- Department of Rehabilitation Medicine, Hanyang University Guri Hospital, Seoul, South Korea
| | - Duk Hyun Sung
- Department of Physical Medicine and Rehabilitation, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kang Hee Cho
- Department of Physical and Rehabilitation Medicine, Chungnam National University, Daejeon, South Korea
| | - Soo Young Kim
- Department of Family Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
| | - Hyun Jung Kim
- Department of Preventive Medicine, Institute for Evidence-based Medicine, Cochrane Korea, College of Medicine, Korea University, Seoul, South Korea
| | - Woong Ju
- Department of Obstetrics and Gynecology, Ewha Womans University, Seoul, South Korea
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Strenge KB, DiPaola CP, Miller LE, Hill CP, Whitmore RG. Multicenter study of lumbar discectomy with Barricaid annular closure device for prevention of lumbar disc reherniation in US patients: A historically controlled post-market study protocol. Medicine (Baltimore) 2019; 98:e16953. [PMID: 31464935 PMCID: PMC6736093 DOI: 10.1097/md.0000000000016953] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 08/01/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Patients with large defects in the annulus fibrosus following lumbar discectomy have high rates of symptomatic reherniation. The Barricaid annular closure device provides durable occlusion of the annular defect and has been shown to significantly lower the risk of symptomatic reherniation in a large European randomized trial. However, the performance of the Barricaid device in a United States (US) population has not been previously reported. DESIGN AND METHODS This is a historically controlled post-market multicenter study to determine the safety and efficacy of the Barricaid device when used in addition to primary lumbar discectomy in a US population. A total of 75 patients with large annular defects will receive the Barricaid device following lumbar discectomy at up to 25 sites in the US and will return for clinical and imaging follow-up at 4 weeks, 3 months, and 1 year. Trial oversight will be provided by a data safety monitoring board and imaging studies will be read by an independent imaging core laboratory. Patients treated with the Barricaid device in a previous European randomized trial with comparable eligibility criteria, surgical procedures, and outcome measures will serve as historical controls. Main outcomes will include back pain severity, leg pain severity, Oswestry Disability Index, health utility on the EuroQol-5 Dimension questionnaire, complications, symptomatic reherniation, and reoperation. Propensity score adjustment using inverse probability of treatment weighting will be used to adjust for differences in baseline patient characteristics between the US trial participants and European historical controls. ETHICS AND DISSEMINATION This study was approved by a central institutional review board. The study results of this trial will be widely disseminated at conference proceedings and published in peer-reviewed journals. The outcomes of this study will have important clinical and economic implications for all stakeholders involved in treating patients with lumbar discectomy in the US. STUDY REGISTRATION ClinicalTrials.gov (https://clinicaltrials.gov): NCT03986580. LEVEL OF EVIDENCE 3.
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Affiliation(s)
| | - Christian P. DiPaola
- Department of Orthopaedics and Rehabilitation, UMass Memorial Medical Center, Worcester
| | - Larry E. Miller
- Miller Scientific Consulting, Inc., Asheville, North Carolina
| | | | - Robert G. Whitmore
- Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
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23
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Ardeshiri A, Miller LE, Thomé C. Two-year real-world results of lumbar discectomy with bone-anchored annular closure in patients at high risk of reherniation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:2572-2578. [PMID: 31227968 DOI: 10.1007/s00586-019-06036-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/05/2019] [Accepted: 06/16/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE To determine the safety and effectiveness of limited lumbar discectomy with additional implantation of an annular closure device (ACD) among patients at high risk of herniation recurrence treated in routine clinical practice. METHODS This was a prospective, single-center study of lumbar discectomy for sciatica caused by intervertebral disc herniation with adjunctive ACD implantation to reduce herniation recurrence risk among high-risk patients with large annular defects. Patients returned for follow-up visits at 6 weeks, 12 weeks, 26 weeks, 1 year, and 2 years. Main outcomes included reoperation, herniation recurrence, back pain severity, leg pain severity, and Oswestry Disability Index (ODI). The minimum important difference was defined as ≥ 20 mm decrease relative to baseline for leg pain severity, ≥ 20 mm decrease for back pain severity, and ≥ 15-point decrease for ODI. RESULTS Among 75 high-risk patients (mean age 45 years, 59% female), the cumulative event incidence through 2 years was 4.0% for reoperation and 1.4% for herniation recurrence. Mean leg pain severity decreased from 73 to 6 (p < 0.001), back pain severity decreased from 51 to 13 (p < 0.001), and ODI decreased from 49 to 7 (p < 0.001). The percentage of patients achieving the minimum important difference was 91% for leg pain, 65% for back pain, and 94% for ODI. CONCLUSION In patients at high risk of herniation recurrence following limited lumbar discectomy in routine clinical practice, additional implantation of an ACD was safe and reherniation recurrence rates were low at 2-year follow-up, which is favorably compared to reported rates in high-risk patients.
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Affiliation(s)
- Ardeshir Ardeshiri
- Section for Spine Surgery, Klinikum Itzehoe, Robert-Koch-Str. 2, 25524, Itzehoe, Germany.
| | - Larry E Miller
- Miller Scientific Consulting, Inc., 1854 Hendersonville Road, #231, Asheville, NC, USA
| | - Claudius Thomé
- Department for Neurosurgery, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
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24
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Bouma GJ, Ardeshiri A, Miller LE, Van de Kelft E, Bostelmann R, Klassen PD, Flüh C, Kuršumović A. Clinical performance of a bone-anchored annular closure device in older adults. Clin Interv Aging 2019; 14:1085-1094. [PMID: 31354252 PMCID: PMC6590844 DOI: 10.2147/cia.s208098] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 05/14/2019] [Indexed: 01/22/2023] Open
Abstract
Background: Lumbar discectomy is a common surgical procedure in middle-aged adults. However, outcomes of lumbar discectomy among older adults are unclear. Methods: Lumbar discectomy patients with an annular defect ≥6 mm width were randomized to receive additional implantation with a bone-anchored annular closure device (ACD, n=272) or no additional implantation (controls, n=278). Over 3 years follow-up, main outcomes were symptomatic reherniation, reoperation, and the percentage of patients who achieved the minimum clinically important difference (MCID) without a reoperation for leg pain, Oswestry Disability Index (ODI), SF-36 Physical Component Summary (PCS) score, and SF-36 Mental Component Summary (MCS) score. Results were compared between older (≥60 years) and younger (<60 years) patients. We additionally analyzed data from two postmarket ACD registries to determine consistency of outcomes between the randomized trial and postmarket, real-world results. Results: Among all patients, older patients suffered from crippling or bed-bound preoperative disability more frequently than younger patients (57.9% vs 39.1%, p=0.03). Among controls, female sex, higher preoperative ODI, and current smoking status, but not age, were associated with greater risk of reherniation and reoperation. Compared to controls, the ACD group had lower risk of symptomatic reherniation (HR=0.45, p<0.001) and reoperation (HR=0.54, p=0.008), with risk reductions comparable in older vs younger patients. The percentage of patients achieving the MCID without a reoperation was higher in the ACD group for leg pain (81% vs 72%, p=0.04), ODI (82% vs 73%, p=0.03), PCS (85% vs 75%, p=0.01), and MCS (59% vs 46%, p=0.007), and this benefit was comparable in older versus younger patients. Comparable benefits in older patients were observed in the postmarket ACD registries. Conclusion: Outcomes with lumbar discectomy and additional bone-anchored ACD are superior to lumbar discectomy alone. Older patients derived similar benefits with additional bone-anchored ACD implantation as younger patients.
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Affiliation(s)
- Gerrit J Bouma
- Department of Neurosurgery, OLVG and Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | | | | | - Erik Van de Kelft
- Department of Neurosurgery, AZ Nikolaas, Sint-Niklaas, Belgium
- Antwerp University, Antwerp, Belgium
| | - Richard Bostelmann
- Department of Neurosurgery, University Clinic Düsseldorf, Duesseldorf, Germany
| | - Peter D Klassen
- Department of Neurosurgery, St. Bonifatius Hospital, Lingen, Germany
| | - Charlotte Flüh
- Department of Neurosurgery, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Adisa Kuršumović
- Department of Neurosurgery, Donauisar Klinikum Deggendorf, Deggendorf, Germany
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Jungen MJ, Ter Meulen BC, van Osch T, Weinstein HC, Ostelo RWJG. Inflammatory biomarkers in patients with sciatica: a systematic review. BMC Musculoskelet Disord 2019; 20:156. [PMID: 30967132 PMCID: PMC6456959 DOI: 10.1186/s12891-019-2541-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 03/28/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND This systematic review focusses on inflammation as an underlying pathogenic mechanism in sciatica. We addressed two questions in particular: (1) what inflammatory biomarkers have been identified in patients with sciatica in the literature so far? 2) is there an association between the level of inflammatory activity and clinical symptoms? METHODS The search was conducted up to December 19th 2018 in MEDLINE, EMBASE, CENTRAL and Web of Science. The study selection criteria: (1) observational cohort studies, cross-sectional studies and randomized clinical trials (RCT), (2) adult population (≥ 18 years) population with sciatica, (3) concentrations of inflammatory biomarkers measured in serum, cerebrospinal fluid (CSF) or biopsies, and (4) evaluation of clinically relevant outcome measures (pain or functional status). Three reviewers independently selected studies and extracted data regarding the study characteristics and the outcomes. Risk of Bias was evaluated using an adjusted version of the Quality in Prognosis Studies (QUIPS) tool. RESULTS In total 16 articles fulfilled the criteria for inclusion: 7 cross sectional observational studies and 9 prospective cohort studies that included a total of 1212 patients. With regard to question 1) the following markers were identified: interleukin (IL)-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-17, IL-21, tumor necrosis factor-α (TNF-α), phospholipase A2, high sensitivity C-reactive protein (hsCRP), C-X-C motif chemokine 5 (CXCM5), CX3CL1, CCL2, epidermal growth factor (EGF), and monocyte chemotactic protein 4 (MCP-4). With regard to question 2) several positive correlations were found in longitudinal studies: a strong positive correlation between inflammatory mediators or byproducts and pain (measured by visual analogue scale, VAS) was found for IL-21 in two studies (r > 0,8), and moderate positive correlations for TNF-a in both serum (r = 0,629) and biopsy (r = 0.65); severe pain (VAS > 4) is associated with increased hsCRP levels among patients with sciatica (adjusted OR = 3.4 (95% CI, 1.1 to 10). CONCLUSION In this systematic review there was considerable heterogeneity in the type of biomarkers and in the clinical measurements in the included studies. Taking into account the overall risk of bias of the included studies there is insufficient evidence to draw firm conclusions regarding the relationship between inflammation and clinical symptoms in patients with sciatica.
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Affiliation(s)
| | - Bastiaan C Ter Meulen
- Department of Neurology, OLVG, Amsterdam, The Netherlands. .,Department of Neurology, Zaans Medisch Centrum, Zaandam, The Netherlands.
| | - Tim van Osch
- Department of Neurology, OLVG, Amsterdam, The Netherlands
| | - Henry C Weinstein
- Department of Neurology, OLVG, Amsterdam, The Netherlands.,Department of Neurology, Zaans Medisch Centrum, Zaandam, The Netherlands
| | - Raymond W J G Ostelo
- Department of Health Sciences, VU University, De Boelelaan, 1081, Amsterdam, HV, Netherlands.,Department of Epidemiology and Biostatistics and the Amsterdam Movement Sciences Research Institute, Amsterdam UMC, De Boelelaan, 1081, Amsterdam, HV, Netherlands
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Nonsurgical medical treatment in the management of pain due to lumbar disc prolapse: A network meta-analysis. Semin Arthritis Rheum 2019; 49:303-313. [PMID: 30940466 DOI: 10.1016/j.semarthrit.2019.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 02/20/2019] [Accepted: 02/22/2019] [Indexed: 11/24/2022]
Abstract
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.
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Arts MP, Kuršumović A, Miller LE, Wolfs JF, Perrin JM, Van de Kelft E, Heidecke V. Comparison of treatments for lumbar disc herniation: Systematic review with network meta-analysis. Medicine (Baltimore) 2019; 98:e14410. [PMID: 30762743 PMCID: PMC6408089 DOI: 10.1097/md.0000000000014410] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/08/2019] [Accepted: 01/14/2019] [Indexed: 12/02/2022] Open
Abstract
STUDY DESIGN Systematic review with network meta-analysis. OBJECTIVE To compare patient outcomes of lumbar discectomy with bone-anchored annular closure (LD + AC), lumbar discectomy (LD), and continuing conservative care (CC) for treatment of lumbar disc herniation refractory to initial conservative management. SUMMARY OF BACKGROUND DATA Several treatment options are available to patients with refractory symptoms of lumbar disc herniation, but their comparative efficacy is unclear. METHODS A systematic review was performed to compare efficacy of LD + AC, LD, and CC for treatment of lumbar disc herniation. Outcomes included leg pain, back pain, disability (each reported on a 0-100 scale), reherniation, and reoperation. Data were analyzed using random effects network meta-analysis. RESULTS This review included 14 comparative studies (8 randomized) involving 3947 patients-11 studies of LD versus CC (3232 patients), 3 studies of LD + AC versus LD (715 patients), and no studies of LD + AC versus CC. LD was more effective than CC in reducing leg pain (mean difference [MD] -10, P < .001) and back pain (MD -7, P < .001). LD + AC was more effective than LD in reducing risk of reherniation (odds ratio 0.38, P < .001) and reoperation (odds ratio 0.33, P < .001). There was indirect evidence that LD + AC was more effective than CC in reducing leg pain (MD -25, P = .003), back pain (MD -20, P = .02), and disability (MD -13, P = .02) although the treatment effect was smaller in randomized trials. CONCLUSIONS Results of a network meta-analysis show LD is more effective than CC in alleviating symptoms of lumbar disc herniation refractory to initial conservative management. Further, LD + AC lowers risk of reherniation and reoperation versus LD and may improve patient symptoms more than CC.
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Affiliation(s)
- Mark P. Arts
- Department of Neurosurgery, Haaglanden Medical Center Westeinde, The Hague, The Netherlands
| | - Adisa Kuršumović
- Department of Neurosurgery, Donauisar Klinikum Deggendorf, Deggendorf, Germany
| | | | - Jasper F.C. Wolfs
- Department of Neurosurgery, Haaglanden Medical Center Westeinde Antoniushove, Leidschendam, The Netherlands
| | - Jason M. Perrin
- Department of Neurosurgery, University Clinic Mannheim, Mannheim, Germany
| | | | - Volkmar Heidecke
- Department of Neurosurgery, Klinikum Augsburg, Augsburg, Germany
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28
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Ament J, Thaci B, Yang Z, Kulubya E, Hsu W, Bouma G, Kim KD. Cost-effectiveness of a Bone-anchored Annular Closure Device Versus Conventional Lumbar Discectomy in Treating Lumbar Disc Herniations. Spine (Phila Pa 1976) 2019; 44:5-16. [PMID: 29927860 DOI: 10.1097/brs.0000000000002746] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cost-utility analysis of an annular closure device (ACD) based on data from a prospective, multicenter randomized controlled trial (RCT) OBJECTIVE.: The aim of this study was to determine the cost-effectiveness of a novel ACD in a patient population at high risk for recurrent herniation following discectomy. SUMMARY OF BACKGROUND DATA Lumbar disc herniation patients with annular defect widths ≥6 mm are at high risk for recurrent herniation following limited discectomy. Recurrent herniation is associated with worse clinical outcomes and greater healthcare costs. A novel ACD may reduce the incidence of recurrent herniation and the associated burdens. METHODS A decision analytical modeling approach with a Markov method was used to evaluate the cost-effectiveness of the ACD versus conventional discectomy. Health states were created by projecting visual analogue scale (VAS) onto Oswestry Disability Index (ODI). Direct costs were calculated based on Humana and Medicare 2014 claims to represent private and public payer data, respectively. Indirect costs were calculated for lost work days using 2016 US average annual wages. The incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life year (QALY) was compared to willingness-to-pay thresholds. Sensitivity analyses were also conducted. RESULTS Patients with the ACD had less symptomatic reherniations, reoperations, and complications and gained 0.0328 QALYs within the first 2 years. Total direct medical costs for the ACD group were similar to control. When productivity loss was considered, using the ACD became $2076 cheaper, per patient, than conventional discectomy. Based on direct costs alone, the ICER comparing ACD to control equaled $6030 per QALY. When indirect costs are included, the ICER became negative, which indicates that superior quality of life was attained at less cost. CONCLUSION For lumbar disc herniations patients with annular defects ≥6 mm, the ACD was, at 2 years, a highly cost-effective surgical modality compared to conventional lumbar discectomy. LEVEL OF EVIDENCE 1.
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Affiliation(s)
- Jared Ament
- Department of Neurological Surgery, University of California, Davis, Sacramento, CA
| | - Bart Thaci
- Department of Neurological Surgery, University of California, Davis, Sacramento, CA
| | - Zhuo Yang
- Department of Neurological Surgery, University of California, Davis, Sacramento, CA
| | - Edwin Kulubya
- Department of Neurological Surgery, University of California, Davis, Sacramento, CA
| | - Wellington Hsu
- Department of Orthopedic Surgery, Northwestern University, Chicago, IL
| | - Gerrit Bouma
- Department of Neurosurgery, OLVG Hospital Amsterdam, the Netherlands
| | - Kee D Kim
- Department of Neurological Surgery, University of California, Davis, Sacramento, CA
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Thomé C, Klassen PD, Bouma GJ, Kuršumović A, Fandino J, Barth M, Arts M, van den Brink W, Bostelmann R, Hegewald A, Heidecke V, Vajkoczy P, Fröhlich S, Wolfs J, Assaker R, Van de Kelft E, Köhler HP, Jadik S, Eustacchio S, Hes R, Martens F. Annular closure in lumbar microdiscectomy for prevention of reherniation: a randomized clinical trial. Spine J 2018; 18:2278-2287. [PMID: 29730458 DOI: 10.1016/j.spinee.2018.05.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 04/25/2018] [Accepted: 05/01/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Patients with large annular defects after lumbar discectomy for disc herniation are at high risk of symptomatic recurrence and reoperation. PURPOSE The present study aimed to determine whether a bone-anchored annular closure device, in addition to lumbar microdiscectomy, resulted in lower reherniation and reoperation rates plus increased overall success compared with lumbar microdiscectomy alone. DESIGN This is a multicenter, randomized superiority study. PATIENT SAMPLE Patients with symptoms of lumbar disc herniation for at least 6 weeks with a large annular defect (6-10 mm width) after lumbar microdiscectomy were included in the study. OUTCOME MEASURES The co-primary end points determined a priori were recurrent herniation and a composite end point consisting of patient-reported, radiographic, and clinical outcomes. Study success required superiority of annular closure on both end points at 2-year follow-up. METHODS Patients received lumbar microdiscectomy with additional bone-anchored annular closure device (n=276 participants) or lumbar microdiscectomy only (control; n=278 participants). This research was supported by Intrinsic Therapeutics. Two authors received study-specific support morethan $10,000 per year, 8 authors received study-specific support less than $10,000 per year, and 11 authors received no study-specific support. RESULTS Among 554 randomized participants, 550 (annular closure device: n=272; control: n=278) were included in the modified intent-to-treat efficacy analysis and 550 (annular closure device: n=267; control: n=283) were included in the as-treated safety analysis. Both co-primary end points of the study were met, with recurrent herniation (50% vs. 70%, P<.001) and composite end point success (27% vs. 18%, P=.02) favoring annular closure device. The frequency of symptomatic reherniation was lower with annular closure device (12% vs. 25%, P<.001). There were 29 reoperations in 24 patients in the annular closure device group and 61 reoperations in 45 control patients. The frequency of reoperations to address recurrent herniation was 5% with annular closure device and 13% in controls (P=.001). End plate changes were more prevalent in the annular closure device group (84% vs. 30%, P<.001). Scores for back pain, leg pain, Oswestry Disability Index, and health-related quality of life at regular visits were comparable between groups over 2-year follow-up. CONCLUSIONS In patients at high risk of herniation recurrence after lumbar microdiscectomy, annular closure with a bone-anchored implant lowers the risk of symptomatic recurrence and reoperation. Additional study to determine outcomes beyond 2 years with a bone-anchored annular closure device is warranted.
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Affiliation(s)
- Claudius Thomé
- Department of Neurosurgery, Medical University Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria.
| | - Peter Douglas Klassen
- Department of Neurosurgery, St. Bonifatius Hospital, Wilhelmstrasse 13, 49808, Lingen, Germany
| | - Gerrit Joan Bouma
- Department of Neurosurgery, OLVG-West and Academic Medical Center, Jan Tooropstraat 164, 1006 AE, Amsterdam, The Netherlands
| | - Adisa Kuršumović
- Department of Neurosurgery, Donauisar Klinikum Deggendorf, Perlasbergerstrasse 41, 94469, Deggendorf, Germany
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse 25, CH-5001, Aarau, Switzerland
| | - Martin Barth
- Department of Neurosurgery, University Hospital Bochum, In der Schornau 23-25, D-44892, Bochum, Germany
| | - Mark Arts
- Department of Neurosurgery, MCH Antoniushove, Albinusdreef 2, 2333 ZA Leiden, The Hague, The Netherlands
| | - Wimar van den Brink
- Neurochirurgisch Centrum Zwolle, Isala Ziekenhuis, Location Sophia P2.25, Dr van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - Richard Bostelmann
- Department of Neurosurgery, University Hospital Düsseldorf, Moorenstrasse 5, House 13.71, D-40225, Düsseldorf, Germany
| | - Aldemar Hegewald
- Department of Neurosurgery, Universitätsmedizin Mannheim, Theodore-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Volkmar Heidecke
- Department of Neurosurgery, Klinikum Augsburg, Stegelinstrasse 2, 86156, Augsburg, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité Universitätsmedizin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Susanne Fröhlich
- Department of Orthopedics, Universität Rostock, Doberaner Str. 142, 18055, Rostock, Germany
| | - Jasper Wolfs
- Department of Neurosurgery, MCH Westenide, Albinusdreef 2, 2333 ZA Leiden, The Hague, The Netherlands
| | - Richard Assaker
- Department of Neurosurgery, Centre Hospitalier Régional Universitaire de Lille, 2 Avenue Oscar Lambret, 59000, Lille, France
| | - Erik Van de Kelft
- Department of Neurosurgery, AZ Nikolaas, Moerlandstraat 1, B-9100, Sint-Niklaas, Belgium
| | - Hans-Peter Köhler
- Department of Neurosurgery, Asklepios Westklinikum Hamburg, Suurheid 20, D-22559, Hamburg, Germany
| | - Senol Jadik
- Department of Neurosurgery, University Hospital Kiel, University Medical Center Schleswig-Holstein, Arnold-Heller-Str. 3, Haus 41, 24105, Kiel, Germany
| | - Sandro Eustacchio
- Department of Neurosurgery, LKH University Klinikum Graz, Auenbrugggerplatz 1, 8036, Graz, Austria
| | - Robert Hes
- Department of Neurosurgery, AZ Klina, Augustijnslei 100, 2930, Brasschaat, Belgium
| | - Frederic Martens
- Department of Neurosurgery, OLV Ziekenhuis, Moorselbaan 164, 9300, Aalst, Belgium
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Abstract
When managing acute nonspecific low back pain (LBP), bed rest is commonly discouraged as a form of therapy. However, when the picture includes radiating leg pain arising from the lumbar spine, the evidence is less robust. In this Viewpoint, the authors explore evidence pertaining to sciatica, defined as "low back pain with verified neurological deficits," and bed rest as part of the management of radiating leg pain. J Orthop Sports Phys Ther 2018;48(6):436-438. doi:10.2519/jospt.2018.0609.
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The Long-Term Course of Outcomes for Lumbar Intervertebral Disc Herniation following Integrated Complementary and Alternative Medicine Inpatient Treatment: A Prospective Observational Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2017; 2017:5239719. [PMID: 28928789 PMCID: PMC5592013 DOI: 10.1155/2017/5239719] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 06/30/2017] [Accepted: 07/18/2017] [Indexed: 12/25/2022]
Abstract
A prospective observational study was conducted in 524 lumbar intervertebral disc herniation (LDH) inpatients to report the long-term effects of complementary and alternative medicine (CAM) treatment. Participants received integrative CAM treatment during hospitalization, from June 2012 to May 2013, and long-term outcomes were assessed from July to August 2016. Numerical rating scales (NRSs) of back and leg pain, the Oswestry disability index (ODI), satisfaction, surgery, recurrence, and current care status were investigated. Baseline characteristics were analyzed to determine factors that predicted long-term satisfaction. A total of 367 patients were available for follow-up. The long-term change in NRS of back and leg pain and ODI was 3.53 (95% CI, 3.22, 3.83), 2.72 (2.34, 3.11), and 32.89 (30.21, 35.57), respectively, showing that improvements were well sustained. Regarding satisfaction, 86.11% responded that they were “slightly improved” or better. Range of lumbar flexion ≤ 60° and both legs' pain at admission were significant predictors of “much improved” or better satisfaction in the long term. Overall, LDH patients who received CAM treatment maintained favorable states in the long term. However, as an uncontrolled observational study, further studies with placebo and/or active controls are warranted. Trial Registration. This trial is registered with ClinicalTrials.gov NCT02257723 (date of registration: October 2, 2014).
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Oosterhuis T, Ostelo RW, van Dongen JM, Peul WC, de Boer MR, Bosmans JE, Vleggeert-Lankamp CL, Arts MP, van Tulder MW. Early rehabilitation after lumbar disc surgery is not effective or cost-effective compared to no referral: a randomised trial and economic evaluation. J Physiother 2017; 63:144-153. [PMID: 28668558 DOI: 10.1016/j.jphys.2017.05.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 05/12/2017] [Accepted: 05/18/2017] [Indexed: 01/24/2023] Open
Abstract
QUESTION Is referral for early rehabilitation after lumbar disc surgery effective and cost-effective compared to no referral? DESIGN Multicentre, randomised, controlled trial, and economic evaluation with concealed allocation and intention-to-treat-analysis. PARTICIPANTS Adults who underwent discectomy for a herniated lumbar disc, confirmed by magnetic resonance imaging, and signs of nerve root compression corresponding to the herniation level. INTERVENTION Early rehabilitation (exercise therapy) for 6 to 8 weeks, versus no referral, immediately after discharge. OUTCOME MEASURES In line with the recommended core outcome set, the co-primary outcomes were: functional status (Oswestry Disability Index); leg and back pain (numerical rating scale 0 to 10); global perceived recovery (7-point Likert scale); and general physical and mental health (SF12), assessed 3, 6, 9, 12 and 26 weeks after surgery. The outcomes for the economic evaluation were quality of life and costs, measured at 6, 12 and 26 weeks after surgery. RESULTS There were no clinically relevant or statistically significant overall mean differences between rehabilitation and control for any outcome adjusted for baseline characteristics: global perceived recovery (OR 1.0, 95% CI 0.6 to 1.7), functional status (MD 1.5, 95% CI -3.6 to 6.7), leg pain (MD 0.1, 95% CI -0.7 to 0.8), back pain (MD 0.3, 95% CI -0.3 to 0.9), physical health (MD -3.5, 95% CI -11.3 to 4.3), and mental health (MD -4.1, 95% CI -9.4 to 1.3). After 26 weeks, there were no significant differences in quality-adjusted life years (MD 0.01, 95% CI -0.02 to 0.04 points) and societal costs (MD -€527, 95% CI -2846 to 1506). The maximum probability for the intervention to be cost-effective was 0.75 at a willingness-to-pay of €32 000/quality-adjusted life year. CONCLUSION Early rehabilitation after lumbar disc surgery was neither more effective nor more cost-effective than no referral. TRIAL REGISTRATION Netherlands Trial Register NTR3156. [Oosterhuis T, Ostelo RW, van Dongen JM, Peul WC, de Boer MR, Bosmans JE, Vleggeert-Lankamp CL, Arts MP, van Tulder MW (2017) Early rehabilitation after lumbar disc surgery is not effective or cost-effective compared to no referral: a randomised trial and economic evaluation. Journal of Physiotherapy 63: 144-153].
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Affiliation(s)
- Teddy Oosterhuis
- Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam; the EMGO+ Institute for Health and Care Research, Amsterdam
| | - Raymond W Ostelo
- Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam; the EMGO+ Institute for Health and Care Research, Amsterdam; Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam
| | - Johanna M van Dongen
- Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam; the EMGO+ Institute for Health and Care Research, Amsterdam
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden; Department of Neurosurgery, Medical Center Haaglanden, The Hague, the Netherlands
| | - Michiel R de Boer
- Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam; the EMGO+ Institute for Health and Care Research, Amsterdam
| | - Judith E Bosmans
- Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam; the EMGO+ Institute for Health and Care Research, Amsterdam
| | | | - Mark P Arts
- Department of Neurosurgery, Medical Center Haaglanden, The Hague, the Netherlands
| | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam; the EMGO+ Institute for Health and Care Research, Amsterdam
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Ter Meulen BC, Maas ET, Vyas A, van der Vegt M, de Priester K, de Boer MR, van Tulder MW, Weinstein HC, Ostelo RWJG. Treatment of acute sciatica with transforaminal epidural corticosteroids and local anesthetic: design of a randomized controlled trial. BMC Musculoskelet Disord 2017; 18:215. [PMID: 28545491 PMCID: PMC5445356 DOI: 10.1186/s12891-017-1571-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 05/11/2017] [Indexed: 12/28/2022] Open
Abstract
Background Transforaminal epidural injections with steroids (TESI) are used increasingly for patients with sciatica. However there is much debate about their safety and effectiveness. It is important to identify patients that benefit most from TESI and only few trials have yet evaluated the effects in patients with acute sciatica. Methods We describe a prospective, randomized controlled trial (RCT), with the aim to evaluate the hypothesis that TESI plus Levobupivacaine (TESI-plus) added to oral pain medication is more effective compared to pain medication alone or compared to transforaminal injection with a local anesthetic of short duration among patients with acute sciatica. We will recruit a total of 264 patients with sciatica (<8 weeks) caused by a herniated disc, from two clinical sites. Participants are randomly assigned one of three study groups: 1) oral pain medication (control group), 2) oral pain medication and TESI-plus (intervention group one), 3) oral pain medication and transforaminal epidural injection (TEI) with Levobupivaine and saline solution (intervention group two). Primary outcomes are functional status (Roland-Morris Disability Questionnaire), pain intensity for both leg and back, (100 mm visual analogous scale (VAS)), and global perceived recovery (GPR, reported on a 7-point Likert scale, dichotomized into ‘recovered’ and ‘not recovered’). The secondary outcomes are health-related quality of life (EQ5D-5 L) and patient satisfaction (7-point Likert scale). We will also collect information on healthcare utilization and costs, to perform an economic evaluation. All outcomes are measured at three and six weeks, three and six months after randomization. We defined a minimal clinically relevant difference between groups as a difference between both intervention groups and the control group of 20 points for pain (100-point VAS), four points for functional status (24-point RDQ) and a 20% difference on dichotomized GPR (recovered versus not recovered). Discussion A clinically relevant outcome in favor of TESI-plus implies that future patients with acute sciatica should be recommended TESI-plus within the first few weeks rather than being treated with pain medication alone in order to relieve pain and improve their functioning. In case of a negative result (no relevant differences in outcome between the three study arms), pain medication will remain the mainstay of treatment in the acute stages of sciatica. Trial registration Dutch National trial register: NTR4457 (March, 6th, 2014)
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Affiliation(s)
- Bastiaan C Ter Meulen
- Department of Neurology, Zaans Medisch Centrum, Zaandam and Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
| | - Esther T Maas
- Department of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Amrita Vyas
- Department of Neurology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | - Koo de Priester
- Department of Radiology Zaans Medisch Centrum, Zaandam, The Netherlands
| | - Michiel R de Boer
- Department of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Maurits W van Tulder
- Department of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands.,Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Henry C Weinstein
- Department of Neurology, Zaans Medisch Centrum, Zaandam and Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Raymond W J G Ostelo
- Department of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands.,Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
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Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M, Andersen MØ, Fournier G, Højgaard B, Jensen MB, Jensen LD, Karbo T, Kirkeskov L, Melbye M, Morsel-Carlsen L, Nordsteen J, Palsson TS, Rasti Z, Silbye PF, Steiness MZ, Tarp S, Vaagholt M. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:60-75. [DOI: 10.1007/s00586-017-5099-2] [Citation(s) in RCA: 294] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/19/2017] [Accepted: 04/10/2017] [Indexed: 01/08/2023]
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Gulati S, Madsbu MA, Solberg TK, Sørlie A, Giannadakis C, Skram MK, Nygaard ØP, Jakola AS. Lumbar microdiscectomy for sciatica in adolescents: a multicentre observational registry-based study. Acta Neurochir (Wien) 2017; 159:509-516. [PMID: 28091818 PMCID: PMC5306165 DOI: 10.1007/s00701-017-3077-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 01/04/2017] [Indexed: 11/28/2022]
Abstract
Background Lumbar disc herniation (LDH) is rare in the adolescent population. Factors predisposing to LDH in adolescents differ from adults with more cases being related to trauma or structural malformations. Further, there are limited data on patient-reported outcomes after lumbar microdiscectomy in adolescents. Our aim was to compare clinical outcomes at 1 year following single-level lumbar microdiscectomy in adolescents (13–19 years old) compared to younger adults (20–50 years old) with LDH. Methods Data were collected through the Norwegian Registry for Spine Surgery. Patients were eligible if they had radiculopathy due to LDH, underwent single-level lumbar microdiscectomy between January 2007 and May 2014, and were between 13 and 50 years old at time of surgery. The primary endpoint was change in Oswestry Disability Index (ODI) 1 year after surgery. Secondary endpoints were generic quality of life (EuroQol five dimensions [EQ-5D]), back pain numerical rating scale (NRS), leg pain NRS and complications. Results A total of 3,245 patients were included (97 patients 13–19 years old and 3,148 patients 20–50 years old). A significant improvement in ODI was observed for the whole population, but there was no difference between groups (0.6; 95% CI, −4.5 to 5.8; p = 0.811). There were no differences between groups concerning EQ-5D (−0.04; 95% CI, −0.15 to 0.07; p = 0.442), back pain NRS (−0.4; 95% CI, −1.2 to 0.4; p = 0.279), leg pain NRS (−0.4; 95% CI, −1.2 to 0.5; p = 0.374) or perioperative complications (1.0% for adolescents, 5.1% for adults, p = 0.072). Conclusions The effectiveness and safety of single-level microdiscectomy are similar in adolescents and the adult population at 1-year follow-up.
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Delgado-López PD, Rodríguez-Salazar A, Martín-Alonso J, Martín-Velasco V. [Lumbar disc herniation: Natural history, role of physical examination, timing of surgery, treatment options and conflicts of interests]. Neurocirugia (Astur) 2017; 28:124-134. [PMID: 28130015 DOI: 10.1016/j.neucir.2016.11.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/26/2016] [Accepted: 11/24/2016] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Indication for surgery in lumbar disc herniation (LDH) varies widely depending on the geographical area. DEVELOPMENT A literature review is presented on the natural history, role of physical examination, timing of surgery, evidence-based treatment, and conflicts of interests in LDH. Surgery is shown to provide significant faster relief of pain compared to conservative therapy, although the effect fades after a year. There is no treatment modality better than the rest in terms of pain control and neurological recovery, nor is there a surgical technique clearly superior to simple discectomy. The lack of sound scientific evidence on the surgical indication may contribute to its great geographical variability. CONCLUSIONS Since LDH has a favourable natural history, neuroimaging and surgery should not be considered until after a 6-week period. It is necessary to specify and respect the surgical indications for LDH, avoiding conflicts of interests.
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Zhang B, Xu H, Wang J, Liu B, Sun G. A narrative review of non-operative treatment, especially traditional Chinese medicine therapy, for lumbar intervertebral disc herniation. Biosci Trends 2017; 11:406-417. [DOI: 10.5582/bst.2017.01199] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Bo Zhang
- Department of Traditional Chinese Medicine Orthopedics, Affiliated Hospital of Shandong Academy of Medical Sciences
| | - Haidong Xu
- Department of Traditional Chinese Medicine Orthopedics, Affiliated Hospital of Shandong Academy of Medical Sciences
| | - Juntao Wang
- Department of Traditional Chinese Medicine Orthopedics, Affiliated Hospital of Shandong Academy of Medical Sciences
| | - Bin Liu
- Department of Traditional Chinese Medicine Orthopedics, Affiliated Hospital of Shandong Academy of Medical Sciences
| | - Guodong Sun
- Department of Traditional Chinese Medicine Orthopedics, Affiliated Hospital of Shandong Academy of Medical Sciences
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Pedersen BK, Saltin B. Exercise as medicine - evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports 2016; 25 Suppl 3:1-72. [PMID: 26606383 DOI: 10.1111/sms.12581] [Citation(s) in RCA: 1687] [Impact Index Per Article: 210.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2015] [Indexed: 12/12/2022]
Abstract
This review provides the reader with the up-to-date evidence-based basis for prescribing exercise as medicine in the treatment of 26 different diseases: psychiatric diseases (depression, anxiety, stress, schizophrenia); neurological diseases (dementia, Parkinson's disease, multiple sclerosis); metabolic diseases (obesity, hyperlipidemia, metabolic syndrome, polycystic ovarian syndrome, type 2 diabetes, type 1 diabetes); cardiovascular diseases (hypertension, coronary heart disease, heart failure, cerebral apoplexy, and claudication intermittent); pulmonary diseases (chronic obstructive pulmonary disease, asthma, cystic fibrosis); musculo-skeletal disorders (osteoarthritis, osteoporosis, back pain, rheumatoid arthritis); and cancer. The effect of exercise therapy on disease pathogenesis and symptoms are given and the possible mechanisms of action are discussed. We have interpreted the scientific literature and for each disease, we provide the reader with our best advice regarding the optimal type and dose for prescription of exercise.
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Affiliation(s)
- B K Pedersen
- The Centre of Inflammation and Metabolism and The Center for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - B Saltin
- The Copenhagen Muscle Research Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Affiliation(s)
- Richard A Deyo
- From the Departments of Family Medicine, Medicine, and Public Health and Preventive Medicine, and the Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland (R.A.D.); and the Department of Orthopaedic Surgery and the Dartmouth Institute, Dartmouth Geisel School of Medicine, Hanover, NH (S.K.M.)
| | - Sohail K Mirza
- From the Departments of Family Medicine, Medicine, and Public Health and Preventive Medicine, and the Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland (R.A.D.); and the Department of Orthopaedic Surgery and the Dartmouth Institute, Dartmouth Geisel School of Medicine, Hanover, NH (S.K.M.)
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Shin YS, Shin JS, Lee J, Lee YJ, Kim MR, Ahn YJ, Park KB, Shin BC, Lee MS, Kim JH, Cho JH, Ha IH. A survey among Korea Medicine doctors (KMDs) in Korea on patterns of integrative Korean Medicine practice for lumbar intervertebral disc displacement: Preliminary research for clinical practice guidelines. Altern Ther Health Med 2015; 15:432. [PMID: 26643853 PMCID: PMC4672541 DOI: 10.1186/s12906-015-0956-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 12/03/2015] [Indexed: 12/02/2022]
Abstract
Background Patients seek Korean Medicine (KM) treatment for a broad range of complaints in Korea, but predominantly for musculoskeletal disorders. We investigated lumbar Intervertebral Disc Displacement (IDD) practice patterns of Korean Medicine doctors (KMDs) within a hospital/clinic network specializing in KM treatment of spinal disorders through survey of diagnosis and treatment methods. Methods Questionnaires on clinical practice patterns of KM treatment for lumbar IDD were distributed to 149 KMDs on January 25th, 2015. The questionnaire included items on sociodemographic characteristics, clinical practice patterns, and preferred method of lumbar IDD diagnosis and treatment. KMDs were asked to grade each treatment method for absolute and relative importance in treatment and prognosis, and safety. Results A total 79.19 % KMDs (n = 118/149) completed the survey, and results showed that integrative care mainly consisting of acupuncture, herbal medicine, Chuna manipulation, and pharmacopuncture was administered to IDD patients. The participant KMDs largely relied on radiological findings (MRI and X-ray) for diagnosis. ‘Eight principle pattern identification’, ‘Qi and Blood syndrome differentiation’ and ‘Meridian system syndrome differentiation’ theories were generally used for KM syndrome differentiation. The most frequently prescribed herbal medication was Chungpa-jun, and most commonly used Chuna technique was ‘sidelying lumbar extension displacement treatment’. IDD patients received 1.9 ± 0.3 treatment sessions/week, and KMDs estimated that an average 9.6 ± 3.5 weeks were needed for 80 % pain relief. Conclusions This is the first study to investigate expert opinion on KM treatment of IDD. Further randomized controlled trials and clinical guidelines based on clinical practice patterns of KM are called for. Electronic supplementary material The online version of this article (doi:10.1186/s12906-015-0956-1) contains supplementary material, which is available to authorized users.
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Lewis RA, Williams NH, Sutton AJ, Burton K, Din NU, Matar HE, Hendry M, Phillips CJ, Nafees S, Fitzsimmons D, Rickard I, Wilkinson C. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. Spine J 2015; 15:1461-77. [PMID: 24412033 DOI: 10.1016/j.spinee.2013.08.049] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 07/09/2013] [Accepted: 08/23/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND There are numerous treatment approaches for sciatica. Previous systematic reviews have not compared all these strategies together. PURPOSE To compare the clinical effectiveness of different treatment strategies for sciatica simultaneously. STUDY DESIGN Systematic review and network meta-analysis. METHODS We searched 28 electronic databases and online trial registries, along with bibliographies of previous reviews for comparative studies evaluating any intervention to treat sciatica in adults, with outcome data on global effect or pain intensity. Network meta-analysis methods were used to simultaneously compare all treatment strategies and allow indirect comparisons of treatments between studies. The study was funded by the UK National Institute for Health Research Health Technology Assessment program; there are no potential conflict of interests. RESULTS We identified 122 relevant studies; 90 were randomized controlled trials (RCTs) or quasi-RCTs. Interventions were grouped into 21 treatment strategies. Internal and external validity of included studies was very low. For overall recovery as the outcome, compared with inactive control or conventional care, there was a statistically significant improvement following disc surgery, epidural injections, nonopioid analgesia, manipulation, and acupuncture. Traction, percutaneous discectomy, and exercise therapy were significantly inferior to epidural injections or surgery. For pain as the outcome, epidural injections and biological agents were significantly better than inactive control, but similar findings for disc surgery were not statistically significant. Biological agents were significantly better for pain reduction than bed rest, nonopioids, and opioids. Opioids, education/advice alone, bed rest, and percutaneous discectomy were inferior to most other treatment strategies; although these findings represented large effects, they were statistically equivocal. CONCLUSIONS For the first time, many different treatment strategies for sciatica have been compared in the same systematic review and meta-analysis. This approach has provided new data to assist shared decision-making. The findings support the effectiveness of nonopioid medication, epidural injections, and disc surgery. They also suggest that spinal manipulation, acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be considered. The findings do not provide support for the effectiveness of opioid analgesia, bed rest, exercise therapy, education/advice (when used alone), percutaneous discectomy, or traction. The issue of how best to estimate the effectiveness of treatment approaches according to their order within a sequential treatment pathway remains an important challenge.
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Affiliation(s)
- Ruth A Lewis
- North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP.
| | - Nefyn H Williams
- North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP; North Wales Organisation for Randomised Trials in Health (NWORTH), Bangor University, The Normal Site, Holyhead Road, Gwynedd, UK LL57 2PZ
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, 22-28 Princess Road West, Leicester, UK LE1 6TP
| | - Kim Burton
- Spinal Research Institute, University of Huddersfield, Queensgate, Huddersfield, UK HD1 3DH
| | - Nafees Ud Din
- North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP
| | - Hosam E Matar
- Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield, UK S5 7AU
| | - Maggie Hendry
- North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP
| | - Ceri J Phillips
- School of Human and Health Sciences, Swansea University, Singleton Park, Swansea, UK SA2 8PP
| | - Sadia Nafees
- North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP
| | - Deborah Fitzsimmons
- Spinal Research Institute, University of Huddersfield, Queensgate, Huddersfield, UK HD1 3DH
| | - Ian Rickard
- Green Oak, Dolydd Terrace, Betws-Y-Coed, UK LL24 0BU
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP
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Abstract
Back pain is a common presenting complaint to the emergency department. The key to proper evaluation is a history and physical examination focused on determining if any red flags for serious disease are present. If no red flags are present, the patient most likely has nonspecific back pain and their symptoms will resolve in 4 to 6 weeks. No diagnostic testing is required. For patients with red flags, a focused history and examination in conjunction with diagnostic laboratory tests and imaging determine whether the patient has an emergent condition such as herniated disc, epidural compression, or spinal infection.
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Affiliation(s)
- David Della-Giustina
- Emergency Medicine, Yale School of Medicine, 464 Congress Avenue, Suite 260, New Haven, CT 06519-1315, USA.
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Alentado VJ, Lubelski D, Steinmetz MP, Benzel EC, Mroz TE. Optimal duration of conservative management prior to surgery for cervical and lumbar radiculopathy: a literature review. Global Spine J 2014; 4:279-86. [PMID: 25396110 PMCID: PMC4229372 DOI: 10.1055/s-0034-1387807] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 06/23/2014] [Indexed: 01/13/2023] Open
Abstract
Study Design Literature review. Objective Since the 1970s, spine surgeons have commonly required 6 weeks of failed conservative treatment prior to considering surgical intervention for various spinal pathologies. It is unclear, however, if this standard has been validated in the literature. The authors review the natural history, outcomes, and cost-effectiveness studies relating to the current standard of 6 weeks of nonoperative care prior to surgery for patients with spinal pathologies. Methods A systematic Medline search from 1953 to 2013 was performed to identify natural history, outcomes, and cost-effectiveness studies relating to the optimal period of conservative management prior to surgical intervention for both cervical and lumbar radiculopathy. Demographic information, operative indications, and clinical outcomes are reviewed for each study. Results A total of 5,719 studies were identified; of these, 13 studies were selected for inclusion. Natural history studies demonstrated that 88% of patients with cervical radiculopathy and 70% of patients with lumbar radiculopathy showed improvement within 4 weeks following onset of symptoms. Outcomes and cost-effectiveness studies supported surgical intervention within 8 weeks of symptom onset for both cervical and lumbar radiculopathy. Conclusions There are limited studies supporting any optimal duration of conservative treatment prior to surgery for cervical and lumbar radiculopathy. Therefore, evidence-based conclusions cannot be made. Based on the available literature, we suggest that an optimal timing for surgery following cervical radiculopathy is within 8 weeks of onset of symptoms. A shorter period of 4 weeks may be appropriate based on natural history studies. Additionally, we found that optimal timing for surgery following lumbar radiculopathy is between 4 and 8 weeks. A prospective study is needed to explicitly identify the optimal duration of conservative therapy prior to surgery so that costs may be reduced and patient outcomes improved.
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Affiliation(s)
- Vincent J. Alentado
- Cleveland Clinic Center for Spine Health, Departments of Orthopaedic and Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, United States,Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Daniel Lubelski
- Cleveland Clinic Center for Spine Health, Departments of Orthopaedic and Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, United States,Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States
| | - Michael P. Steinmetz
- Case Western Reserve University School of Medicine, Cleveland, Ohio, United States,Department of Neurosciences, MetroHealth Medical Center, Cleveland, Ohio, United States
| | - Edward C. Benzel
- Cleveland Clinic Center for Spine Health, Departments of Orthopaedic and Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, United States,Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States
| | - Thomas E. Mroz
- Cleveland Clinic Center for Spine Health, Departments of Orthopaedic and Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, United States,Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States,Address for correspondence Thomas E. Mroz, MD Departments of Orthopaedic and Neurological SurgeryCenter for Spine Health, The Cleveland Clinic, 9500 Euclid Avenue, S-40, Cleveland, OH 44195United States
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Germon T, Singleton W, Hobart J. Is NICE guidance for identifying lumbar nerve root compression misguided? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23 Suppl 1:S20-4. [PMID: 24549392 DOI: 10.1007/s00586-014-3233-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Revised: 02/03/2014] [Accepted: 02/04/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE To determine the extent to which the clinical manifestations of a cohort of people undergoing surgery for lumbosacral nerve root compression satisfy those described in The National Institute for Health and Care Excellence (NICE) guidance. METHOD We studied consecutive admissions for lumbar nerve root decompression surgery at two neurosurgical units. Pre-operatively, each person's clinical manifestations were documented and compared with NICE's description. Post-operatively, at three time points (within 48 h, 3 months, 12 months), each person rated their symptoms as either better, the same, or worse. RESULTS Pre-operatively, one person (0.8%), from 123 admissions, under 20 different consultant neurosurgeons, had manifestations consistent with NICE's clinical description of lumbar nerve root compression. Post-operatively, self-reported benefit associated with surgery appeared high, at all three time points (78-91%), supporting the diagnosis of symptomatic nerve root compression and the value of surgery. CONCLUSIONS In this small sample, from two units, NICE's description of the clinical manifestations of lumbar nerve root compression did not describe 99% of people having surgery for it. Using NICE's definition to triage people with low back pain could result in prolonged symptoms and delayed treatment. Diagnosing lumbar nerve root compression is complex. NICE's guidance requires examination.
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Affiliation(s)
- Tim Germon
- Department of Neurosurgery, Derriford Hospital, Plymouth, PL6 8DH, UK,
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Ahmed N, Tufel S, Khan MH, Khan PB. EFFECTIVENESS OF NEURAL MOBILIZATION IN THE MANAGEMENT OF SCIATICA. ACTA ACUST UNITED AC 2013. [DOI: 10.1142/s0218957713500127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Nisar Ahmed
- Jamia Millia Islamia, Jamia Nagar, New Delhi-110025, India
| | - Saba Tufel
- Jamia Hamdard, Hamdard Nagar, New Delhi-110062, India
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