Sciatica: a review of history, epidemiology, pathogenesis, and the role of epidural steroid injection in management

Thoracolumbar hydrated nucleus pulposus extrusion and intervertebral disc extrusion in dogs: comparison of clinical presentation and magnetic resonance imaging findings

Thoracolumbar hydrated nucleus pulposus extrusion (TL-HNPE) is an increasingly recognised pathology with a substantial lack of literature describing its features. The aim of this retrospective case-control study was to analyse the clinical and magnetic resonance imaging (MRI) features of dogs with TL-HNPE compared to dogs affected with thoracolumbar intervertebral disc extrusion (TL-IVDE). Data from dogs diagnosed with TL-HNPE and TL-IVDE via MRI at two referral hospitals, were retrospectively collected and compared in terms of clinical signs and MRI features. Cases diagnosed with TL-IVDE were deemed controls. The MRI features of the affected IVD space, herniated IVD material, affected overlying spinal cord and local epaxial musculature were evaluated for each group. Fifty-one cases with TL-HNPE and 105 randomly selected cases of TL-IVDE were included. Several signalment and neurological signs were identified as statistically distinct between groups in univariate analysis. Multivariate analysis identified that dogs affected with TL-HNPE were typically older, less likely to be chondrodystrophic (62.2% vs. 91%), more frequently experiencing a peracute onset (90.2% vs. 61.9%) often attributed to a suspected trauma linked with exercise (37.3% vs. 10.5%), being less frequently progressive (41.2% vs. 86.5%) and with herniated disc material less frequently lateralised (72.6% vs. 89.5%) than cases with TL-IVDE. MRI-identifiable intervertebral disc degeneration was found in every TL-IVDE case but only in 60% of TL-HNPE cases. TL-HNPEs were associated to significantly less spinal cord compression and less hyperalgesia than TL-IVDE.

A randomized, placebo-controlled trial of long-acting dexamethasone viscous gel delivered by transforaminal injection for lumbosacral radicular pain

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03372161.

Development and validation of a nomogram to predict the risk of residual low back pain after tubular microdiskectomy of lumbar disk herniation

OBJECTIVE

Tubular microdiskectomy (tMD) is one of the most commonly used for treating lumbar disk herniation. However, there still patients still complain of persistent postoperative residual low back pain (rLBP) postoperatively. This study attempts to develop a nomogram to predict the risk of rLBP after tMD.

METHODS

The patients were divided into non-rLBP (LBP VAS score < 2) and rLBP (LBP VAS score ≥ 2) group. The correlation between rLBP and these factors were analyzed by multivariate logistic analysis. Then, a nomogram prediction model of rLBP was developed based on the risk factors screened by multivariate analysis. The samples in the model are randomly divided into training and validation sets in a 7:3 ratio. The Receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to evaluate the diskrimination, calibration and clinical value of the model, respectively.

RESULTS

A total of 14.3% (47/329) of patients have persistent rLBP. The multivariate analysis suggests that higher preoperative LBP visual analog scale (VAS) score, lower facet orientation (FO), grade 2-3 facet joint degeneration (FJD) and moderate-severe multifidus fat atrophy (MFA) are risk factors for postoperative rLBP. In the training and validation sets, the ROC curves, calibration curves, and DCAs suggested the good diskrimination, predictive accuracy between the predicted probability and actual probability, and clinical value of the model, respectively.

CONCLUSION

This nomogram including preoperative LBP VAS score, FO, FJD and MFA can serve a promising prediction model, which will provide a reference for clinicians to predict the rLBP after tMD.

Pulsed radiofrequency of lumbar dorsal root ganglion for lumbar radicular pain: A systematic review and meta-analysis

BACKGROUND

Pulsed radiofrequency (PRF) of the lumbar dorsal root ganglion (DRG) has been widely used as a method to relieve lumbar radicular pain (LRP). However, the value of PRF application in LRP patients remains uncertain. This systematic review aimed to compare the effects of PRF of lumbar DRG and LEI in patients with LRP.

METHODS

A literature search was performed using well-known databases for articles published up to May 2023. We included randomized controlled trials (RCTs) that evaluated the effects of PRF compared to LEI with or without steroids. We screened articles, extracted data, and assessed risk of bias in duplicate. The pain scores and Oswestry Disability Index (ODI) scores at 1, 3, and 6 months after procedures were obtained. A random-effects meta-analysis model was applied for outcomes. We evaluated evidence certainty for each outcome using the GRADE scoring system. This review was registered in the PROSPERO (ID: CRD42021253628).

RESULTS

A total of 10 RCTs were included and data of 613 patients were retrieved. We assessed the overall quality of the evidence as very low to moderate. PRF showed no difference in pain scores at 1 (mean difference [MD] -0.80, 95% confidence interval [CI] -1.59 to 0.00, low certainty) and 6 months (MD -2.37, 95% CI -4.79 to 0.05, very low certainty), and significantly improved pain scores at 3 months (MD -1.31, 95% CI -2.29 to -0.33, low certainty). There was no significant difference in ODI score at any interval (very low to low certainty). In the subgroup who underwent a diagnostic block, did not use steroids, and PRF duration greater than 360 s, PRF significantly reduced pain scores at 3 months after procedures.

CONCLUSIONS

We found low quality of the evidence supporting adjuvant PRF to the lumbar DRG has a greater analgesic effect at 3 months after procedures in patients with LRP than LEI. We identified no convincing evidence to show that this treatment improves function. High-quality evidence is lacking, and data were largely derived from short-term effects. Given these limitations, high-quality trials with data on long-term effects are needed.

Repeated epidural delivery of Shinbaro2: effects on neural recovery, inflammation, and pain modulation in a rat model of lumbar spinal stenosis

The choice of treatment for lumbar spinal stenosis (LSS) depends on symptom severity. When severe motor issues with urinary dysfunction are not present, conservative treatment is often considered to be the priority. One such conservative treatment is epidural injection, which is effective in alleviating inflammation and the pain caused by LSS-affected nerves. In this study, Shinbaro2 (Sh2), pharmacopuncture using natural herbal medicines for patients with disc diseases, is introduced as an epidural to treat LSS in a rat model. The treatment of primary sensory neurons from the rats' dorsal root ganglion (DRG) neurons with Sh2 at various concentrations (0.5, 1, and 2 mg/mL) was found to be safe and non-toxic. Furthermore, it remarkably stimulated axonal outgrowth even under H2O2-treated conditions, indicating its potential for stimulating nerve regeneration. When LSS rats received epidural injections of two different concentrations of Sh2 (1 and 2 mg/kg) once daily for 4 weeks, a significant reduction was seen in ED1+ macrophages surrounding the silicone block used for LSS induction. Moreover, epidural injection of Sh2 in the DRG led to a significant suppression of pain-related factors. Notably, Sh2 treatment resulted in improved locomotor recovery, as evaluated by the Basso, Beattie, and Bresnahan scale and the horizontal ladder test. Additionally, hind paw hypersensitivity, assessed using the Von Frey test, was reduced, and normal gait was restored. Our findings demonstrate that epidural Sh2 injection not only reduced inflammation but also improved locomotor function and pain in LSS model rats. Thus, Sh2 delivery via epidural injection has potential as an effective treatment option for LSS.

Associations of socioeconomic and lifestyle characteristics, psychological symptoms, multimorbidity, and multisite pain with sciatica - a 15-year longitudinal study

BACKGROUND CONTEXT

Sciatica is defined as pain radiating from the low back to the leg, usually below the knee. It is a disabling condition that causes a major burden to health care and society. Previous evidence of the multifactorial etiology of sciatica comes mostly from cross-sectional studies. Larger, longitudinal studies with a multidimensional set of variables are needed.

PURPOSE

To examine how socioeconomic and lifestyle characteristics, psychological symptoms, multimorbidity, and multisite pain are associated with sciatica.

STUDY DESIGN

A longitudinal study of the Northern Finland Birth Cohort 1966.

PATIENT SAMPLE

In total 6,683 working-aged members of the Northern Finland Birth Cohort 1966.

OUTCOME MEASURES

Self-reported sciatic pain status over a 15-year study period.

METHODS

We conducted a 15-year longitudinal study from the age of 31 to 46. We used multivariable generalized estimation equations analysis to examine how socioeconomic characteristics (low education, unemployment, and living alone), lifestyle characteristics (overweight, obesity, current smoking, and physical inactivity), psychological symptoms (depression, anxiety), multimorbidity, and multisite pain were associated with sciatica.

RESULTS

At the age of 31, 21.1% of the study population reported sciatic pain and at the age of 46, 36.7%. Multisite pain was clearly the strongest factor associated with sciatica (odds ratio [OR] 2.61, 95% confidence interval [CI] 2.34‒2.92). In descending order of effect size, older age, low education, psychological symptoms, multimorbidity, overweight, obesity, physical inactivity and current smoking were positively associated with sciatica. Their ORs varied between 1.17 and 2.18. Living alone was negatively associated with sciatica (OR 0.81, 95% CI 0.72‒0.90).

CONCLUSIONS

Multisite pain had the strongest association with sciatica. The effect sizes of the other factors were clearly smaller. To our knowledge this is the first study to evaluate the association of multisite pain with sciatica. This finding may have considerable implications for clinical work treating patients with sciatica.

Surgical vs. Conservative Management of Chronic Sciatica (>3 Months) Due to Lumbar Disc Herniation: Systematic Review and Meta-Analysis

Sciatica, characterized by leg or back symptoms along the sciatic nerve pathway, often manifests as a chronic condition lasting over 12 weeks. Decision-making between nonoperative treatment and immediate microdiscectomy for chronic sciatica remains challenging, due to the complex relationship between symptom duration, severity, and lumbar discectomy outcomes. In this systematic review, we conducted a comprehensive search across Scopus, PubMed, Web of Science, and the Cochrane Library, identifying relevant two-arm clinical trials up to September 2023. Rigorous screening and data extraction were performed by two independent reviewers, with study quality evaluated using the risk of bias 2 (RoB) tool. This meta-analysis incorporated four studies comprising 352 participants. Our analysis revealed that conservative treatment was associated with a significant reduction in leg pain and improvement in, SF mental, and physical scores compared to surgical intervention. However surgical treatment demonstrated significant improvement in back pain. In conclusion, our findings suggest that surgical intervention may be more effective than non-surgical treatment for chronic sciatica-related back pain. Conservative treatment significantly reduces leg pain while improving mental and physical health outcomes. Ultimately, our findings support conservative as the initial approach unless surgery is warranted, particularly in cases with neurological deficits or cauda equina syndrome.

Cauda equina, conus medullaris and syndromes mimicking sciatic pain: WFNS spine committee recommendations

Introduction

Cauda equina syndrome (CES), conus medullaris syndrome (CMS), and sciatica-like syndromes or "sciatica mimics" (SM) may present as diagnostic and/or therapeutic dilemmas for the practicing spine surgeon. There is considerable controversy regarding the appropriate definition and diagnosis of these entities, as well as indications for and timing of surgery. Our goal is to formulate the most current, evidence-based recommendations for the definition, diagnosis, and management of CES, CMS, and SM syndromes.

Methods

We performed a systematic literature search in PubMed from 2012 to 2022 using the keywords "cauda equina syndrome", "conus medullaris syndrome", "sciatica", and "sciatica mimics". Standardized screening criteria yielded a total of 43 manuscripts, whose data was summarized and presented at two international consensus meetings of the World Federation of Neurosurgical Societies (WFNS) Spine Committee. Utilizing the Delphi method, we generated seven final consensus statements.

Results and conclusion

s: We provide standardized definitions of cauda equina, cauda equina syndrome, conus medullaris, and conus medullaris syndrome. We advocate for the use of the Lavy et al classification system to categorize different types of CES, and recommend urgent MRI in all patients with suspected CES (CESS), considering the low sensitivity of clinical examination in excluding CES. Surgical decompression for CES and CMS is recommended within 48 h, preferably within less than 24 h. There is no data regarding the role of steroids in acute CES or CMS. The treating physician should be cognizant of a variety of other pathologies that may mimic sciatica, including piriformis syndrome, and how to manage these.

Acupuncture for radicular pain: a review of analgesic mechanism

Radicular pain, a common and complex form of neuropathic pain, presents significant challenges in treatment. Acupuncture, a therapy originating from ancient traditional Chinese medicine and widely utilized for various pain types, including radicular pain, has shown promising outcomes in the management of lumbar radicular pain, cervical radicular pain, and radicular pain due to spinal stenosis. Despite its efficacy, the exact mechanisms through which acupuncture achieves analgesia are not fully elucidated and are the subject of ongoing research. This review sheds light on the current understanding of the analgesic mechanisms of acupuncture for radicular pain, offering valuable perspectives for both clinical application and basic scientific research. Acupuncture is postulated to relieve radicular pain by several mechanisms: peripherally, it reduces muscle spasms, lessens mechanical pressure on nerve roots, and improves microcirculation; at the molecular level, it inhibits the HMGB1/RAGE and TLR4/NF-κB signaling pathways, thereby decreasing the release of pro-inflammatory cytokines; within the spinal cord, it influences synaptic plasticity; and centrally, it modulates brain function, particularly affecting the medial prefrontal cortex, anterior cingulate cortex, and thalamus within the default mode network. By acting across these diverse biological domains, acupuncture presents an effective treatment modality for radicular pain, and deepening our understanding of the underlying mechanisms regarding analgesia for radicular pain is crucial for enhancing its clinical efficacy and advancement in pain management.

Comparative-Effectiveness study evaluating outcomes for transforaminal epidural steroid injections performed with 3% hypertonic saline or normal saline in lumbosacral radicular pain

BACKGROUND

Transforaminal epidural steroid injection (TFESI) are commonly employed to treat lumbosacral radiculopathy. Despite anti-inflammatory properties, the addition of 3% hypertonic saline has not been studied.

OBJECTIVE

Compare the effectiveness of adding 0.9% NaCl (N-group) vs. 3% NaCl (H-group) in TFESI performed for lumbosacral radiculopathy.

METHODS

This retrospective study compared TFESI performed with lidocaine, triamcinolone and 0.9% NaCl. The primary outcome was the proportion of patients who experienced a ≥ 30% reduction in pain on a verbal rating scale (VRS; 0-100) at 3 months. Secondary outcome measures included the proportion of patients who improved by at least 30% for pain at 1- and 6-months, and who experienced ≥15% from baseline on the Oswestry disability index (ODI) at follow-up.

RESULTS

The H-group experienced more successful pain outcomes than the N-group at 3 months (59.09% vs. 41.51%; P = 0.002) but not at 1 month (67.53% vs. 64.78%; P = 0.61) or 6 months (27.13% vs 21.55%: P = 0.31). For functional outcome, there was a higher proportion of responders in the H-group than N-group at 3 months (70.31% vs. 53.46%; P = 0.002). Female, age ≤ 60 years and duration of pain ≤ 6 months were associated with superior outcomes at the 3-month endpoint. Although those with a herniated disc experienced better outcomes in general with TFESI, the only difference favoring the H-group was for spondylolisthesis patients.

CONCLUSIONS

3% hypertonic saline is a viable alternative to normal saline as an adjunct for TFESI, with randomized studies needed to compare its effectiveness to steroids as a possible alternative.

REGISTRATION

Thai Clinical Trials Registry ID TCTR 20231110006.

Results from an expedited spinal nerve root block clinic at a UK tertiary neurosurgical centre

STUDY DESIGN

Retrospective Observational Study.

INTRODUCTION

Lumbar radicular pain has a prevalence of 3-5%. Level 1 evidence has demonstrated equivalence between surgical and injection treatment. We assess the outcomes from a transforaminal epidural steroid injection clinic in a tertiary neuroscience referral centre.

METHODS

We performed an analysis of data from consecutive patients entered into a new internal referral database between August 2018 to May 2021. Radicular pain was classified as one of "first presentation" or "recurrence". Outcomes were obtained from follow up clinic letters and recorded in a binary manner of "positive result" or "negative result". Spinal pathology was documented from radiology reports and MRI images.

RESULTS

We analysed 208 patients referred to the clinic. Excluding those who improved to a point of not requiring treatment, and those who underwent surgical intervention, 119 patients undergoing injection were included, of which 14 were lost to follow-up. 68 % of patients had a positive result from injection. Subgroup analysis demonstrated good outcomes for both hyperacute (<6 weeks) and chronic (>12 months). Contained disk pathologies had better outcomes than uncontained. There was no difference in outcomes across grades of compression, but previous same level surgery was associated with poorer response rates.

CONCLUSIONS

There is a high rate of natural resolution of symptoms in patients with LSRP. In those where pain persists, TFESI is a valuable first line treatment modality. This study suggests the efficacy of TFESI is potentially independent of grade of stenosis and chronicity of symptoms. Contained disc pathologies respond better than uncontained.

Clinical Value and Reliability of Quantitative Assessments of Lumbosacral Nerve Root Using Diffusion Tensor and Diffusion Weighted MR Imaging: A Systematic Review

BACKGROUND

Lumbosacral radicular pain diagnosis remains challenging. Diffusion tensor imaging (DTI) and diffusion weighted imaging (DWI) have potential to quantitatively evaluate symptomatic nerve root, which may facilitate diagnosis.

PURPOSE

To determine the ability of DTI and DWI metrics, namely fractional anisotropy (FA) and apparent diffusion coefficient (ADC), to discriminate between healthy and symptomatic lumbosacral nerve roots, to evaluate the association between FA and ADC values and patient symptoms, and to determine FA and ADC reliability.

STUDY TYPE

Systematic review.

SUBJECTS

Eight hundred twelve patients with radicular pain with or without radiculopathy caused by musculoskeletal-related compression or inflammation of a single, unilateral lumbosacral nerve root and 244 healthy controls from 29 studies.

FIELD STRENGTH/SEQUENCE

Diffusion weighted echo planar imaging sequence at 1.5 T or 3 T.

ASSESSMENT

An extensive systematic review of the literature was conducted in Embase, Scopus, and Medline databases. FA and ADC values in symptomatic and contralateral lumbosacral nerve roots were extracted and summarized, together with intra- and inter-rater agreements. Where available, associations between DWI or DTI parameters and patient symptoms or symptom duration were extracted.

STATISTICAL TESTS

The main results of the included studies are summarized. No additional statistical analyses were performed.

RESULTS

The DTI studies systematically found significant differences in FA values between the symptomatic and contralateral lumbosacral nerve root of patients suffering from radicular pain with or without radiculopathy. In contrast, identification of the symptomatic nerve root with ADC values was inconsistent for both DTI and DWI studies. FA values were moderately to strongly correlated with several symptoms (eg, disability, nerve dysfunction, and symptom duration). The inter- and intra-rater reliability of DTI parameters were moderate to excellent. The methodological quality of included studies was very heterogeneous.

DATA CONCLUSION

This systematic review showed that DTI was a reliable and discriminative imaging technique for the assessment of symptomatic lumbosacral nerve root, which more consistently identified the symptomatic nerve root than DWI. Further studies of high quality are needed to confirm these results.

EVIDENCE LEVEL

N/A TECHNICAL EFFICACY: Stage 2.

[Efficiency evaluation of the Neuromidin in the treatment of pain of the patients with discogenic lumbosacral radiculopathy: results of a multicenter post-registration prospective open comparative trial]

OBJECTIVE

Evaluation of the effect of Neuromidine on the dynamics of pain syndrome in the treatment of patients with discogenic lumbosacral radiculopathy.

MATERIAL AND METHODS

Patients with a confirmed diagnosis of discogenic lumbosacral radiculopathy no more than one year old and moderate intensity of pain syndrome on a visual analog scale were included in the main group (OH, n=62, age - 53.1±15.6 yrs) and the comparison group (HS, n=40, age - 53.7±12.9 yrs). OG patients received Neuromidine (15 mg/1 mL 1 once a day IM for 10 days, then 20 mg 3 times a day for 8 weeks) in addition to the standard drug therapy, HS patients received only standard drug therapy. The duration of the study was 8 weeks. The degree of decrease in the intensity and dynamics of pain syndrome, activity and frequency of pain in the lumbar spine, changes in the level of physical activity, and the severity of emotional disorders were evaluated. The level of inflammatory markers in the blood and the dynamics of monosynaptic spinal H-reflex parameters were evaluated.

RESULTS

Before the study, there were no statistically significant differences there were no results of clinical and laboratory-instrumental examination between groups. After 8 weeks, the reduction of pain by VAS in the main group was statistically significant in contrast to the comparison group (p=0.0001). In the main group there was a statistically significant increase in the mean cognitive impairment score (p=0.0029), as well as an improvement in psycho-emotional state with a significant decrease in GAD-7 (p=0.0002) and PHQ-9 (p=0.0096). After 8 weeks of therapy, IL-6 level in the main group was statistically significantly lower (p=0.0027) than in the comparison group. The results of H-reflex study revealed an increase in its amplitude and some shortening of latency at the end of Neuromidine therapy. The drug had no undesirable side effects and was well tolerated.

CONCLUSION

Administration of Neuromidine 15 mg/1 ml once a day intramuscularly for 10 days followed by 20 mg 3 times a day for 8 weeks has an effective analgesic effect as adjuvant therapy in patients with discogenic lumbosacral radiculopathy. The inclusion of Neuromidine in the complex treatment of patients with pain syndrome in discogenic radiculopathy is superior in efficacy to standard drug therapy.

Developing a trans-multisynaptic tracer to map the neural circuit of recovered sciatic nerve after treatment with nerve growth factor

Nerve growth factor (NGF) has been shown to support the survival and differentiation of neurons. In this study, we first developed a retrograde trans-multisynaptic tracer PRV580 expressing the mCherry fluorescent protein based on pseudorabies virus Bartha strain to map the neural circuit of sciatic nerve. Secondly, the newly developed PRV580 was used to map the neural circuit of the recovering sciatic nerve upon treatment with NGF. Our results showed that red signals from PRV580 were observed in various brain regions. Among these regions, many areas of the pyramidal system and the extra-pyramidal system had been mapped, accounting for as much as 56.8 % of the total inputs. Furthermore, we found that NGF could significantly increase the ratio of total input (29.05 %) compared to PBS (3.65 %), indicating that NGF indeed can aid in the repair of injured sciatic nerve. These findings indicated that NGF has therapeutic ability for the treatment of peripheral nerve injuries and virus-based tracers can be used to monitor the recovery.

Predictors of outcome in sciatica patients following an epidural steroid injection: the POiSE prospective observational cohort study protocol

INTRODUCTION

Sciatica can be very painful and, in most cases, is due to pressure on a spinal nerve root from a disc herniation with associated inflammation. For some patients, the pain persists, and one management option is a spinal epidural steroid injection (ESI). The aim of an ESI is to relieve leg pain, improve function and reduce the need for surgery. ESIs work well in some patients but not in others, but we cannot identify these patient subgroups currently. This study aims to identify factors, including patient characteristics, clinical examination and imaging findings, that help in predicting who does well and who does not after an ESI. The overall objective is to develop a prognostic model to support individualised patient and clinical decision-making regarding ESI.

METHODS

POiSE is a prospective cohort study of 439 patients with sciatica referred by their clinician for an ESI. Participants will receive weekly text messages until 12 weeks following their ESIand then again at 24 weeks following their ESI to collect data on leg pain severity. Questionnaires will be sent to participants at baseline, 6, 12 and 24 weeks after their ESI to collect data on pain, disability, recovery and additional interventions. The prognosis for the cohort will be described. The primary outcome measure for the prognostic model is leg pain at 6 weeks. Prognostic models will also be developed for secondary outcomes of disability and recovery at 6 weeks and additional interventions at 24 weeks following ESI. Statistical analyses will include multivariable linear and logistic regression with mixed effects model.

ETHICS AND DISSEMINATION

The POiSE study has received ethical approval (South Central Berkshire B Research Ethics Committee 21/SC/0257). Dissemination will be guided by our patient and public engagement group and will include scientific publications, conference presentations and social media.

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

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

Objective

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

Methods

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

Results

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

Conclusion

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

The role of high-resolution ultrasound and MRI in the evaluation of peripheral nerves in the lower extremity

Lower extremity peripheral neuropathy is a commonly encountered neurologic disorder, which can lead to chronic pain, functional disability, and decreased quality of life for a patient. As diagnostic imaging modalities have improved, imaging has started to play an integral role in the detection and characterization of peripheral nerve abnormalities by non-invasively and accurately identifying abnormal nerves as well as potential causes of neuropathy, which ultimately leads to precise and timely treatment. Ultrasound, which has high spatial resolution and can quickly and comfortably characterize peripheral nerves in real time along with associated denervation muscle atrophy, and magnetic resonance neurography, which provides excellent contrast resolution between nerves and other tissues and between pathologic and normal segments of peripheral nerves, in addition to assessing reversible and irreversible muscle denervation changes, are the two mainstay imaging modalities used in peripheral nerve assessment. These two modalities are complimentary, and one may be more useful than the other depending on the nerve and location of pathology. Imaging must be interpreted in the context of available clinical information and other diagnostic studies, such as electrodiagnostic tests. Here, we offer a comprehensive overview of the role of high-resolution ultrasound and magnetic resonance neurography in the evaluation of the peripheral nerves of the lower extremity and their associated neuropathies.

The effect of a topical formulation from Lawsonia inermis L. (henna) on pain intensity in patients with chronic sciatica: A randomized double-blind clinical trial

ETHNOPHARMACOLOGICAL RELEVANCE

Chronic sciatica (CS) is a common condition of disability and pain. Lawsonia inermis L. (henna) is a medicinal plant that is commonly recommended in traditional Persian medicine textbooks for pain relief in patients with sciatica, particularly in the form of oil.

AIM OF THE STUDY

This research was designed to investigate the efficacy of a topical formulation from henna on pain intensity in patients with CS.

METHODS AND MATERIALS

In a randomized, double-blind clinical study, 81 patients were randomly allocated to three groups to receive the topical henna formulation (aqueous extract of henna in sesame oil), sesame oil, or placebo, three times daily, for four weeks. The patients were assessed by visual analog scale (VAS), 36-item short form health survey (SF-36), and Oswestry disability index (ODI).

RESULTS

There was a significant decrease in mean VAS in henna oil compared to sesame oil (p = 0.004) and placebo (p = 0.004). Significant improvements in total SF-36 scores were observed in henna oil and sesame oil compared to placebo (p = 0.011 and p = 0.025, respectively). Furthermore, ODI significantly decreased in henna oil compared to sesame oil (p < 0.001) and placebo (p = 0.005).

CONCLUSION

Henna oil seems to be an effective treatment to reduce pain intensity in patients with CS. Moreover, it improves quality of life and functional ability. Further randomized controlled trials with longer intervention periods are recommended to confirm this efficacy.

A systematic review of genome-wide association studies for pain, nociception, neuropathy, and pain treatment responses

ABSTRACT

Pain is the leading cause of disability worldwide, imposing an enormous burden on personal health and society. Pain is a multifactorial and multidimensional problem. Currently, there is (some) evidence that genetic factors could partially explain individual susceptibility to pain and interpersonal differences in pain treatment response. To better understand the underlying genetic mechanisms of pain, we systematically reviewed and summarized genome-wide association studies (GWASes) investigating the associations between genetic variants and pain/pain-related phenotypes in humans. We reviewed 57 full-text articles and identified 30 loci reported in more than 1 study. To check whether genes described in this review are associated with (other) pain phenotypes, we searched 2 pain genetic databases, Human Pain Genetics Database and Mouse Pain Genetics Database. Six GWAS-identified genes/loci were also reported in those databases, mainly involved in neurological functions and inflammation. These findings demonstrate an important contribution of genetic factors to the risk of pain and pain-related phenotypes. However, replication studies with consistent phenotype definitions and sufficient statistical power are required to validate these pain-associated genes further. Our review also highlights the need for bioinformatic tools to elucidate the function of identified genes/loci. We believe that a better understanding of the genetic background of pain will shed light on the underlying biological mechanisms of pain and benefit patients by improving the clinical management of pain.

Correlation of multifidus degeneration with sex, age and side of herniation in patients with lumbar disc herniation

OBJECTIVE

The aim of this study was to determine the relationship between multifidus degeneration and sex, age and side of protrusion in patients with lumbar disc herniation(LDH).

METHODS

Data were collected from September 2015 to September 2022 from patients with L4/5 and L5/S1 LDH. A total of 104 patients (62 males and 42 females) were included in this study, and there were 35 and 69 cases of L4/5 and L5/S1 LDH, respectively. Patients were divided into 4 groups according to age: group 1 (20-29), group 2 (30-39), group 3 (40-49) and group 4 (50-59). Magnetic resonance spectroscopy analysis was used to observe the fat fraction (FF) and functional cross-sectional area (f-CSA) of the defatted multifidus muscle of the protruding side (affected side) and the nonprotruding side (healthy side) of the L4/5 and L5/S1 gaps to evaluate the relationship between multifidus degeneration and sex, age and protruding side in patients with LDH.

RESULTS

Between sexes, the FF of the multifidus muscle was significantly greater in women than in men, regardless of whether it was on the affected or healthy side of the L4/5 segment or on the affected or healthy side of the L5/S1 segment (P < 0.05). Between age groups, there was a significantly positive relationship between the change in FF (%) of the multifidus muscle in patients with LDH and age, with increasing fatty infiltration of the multifidus increasing with age (P < 0.05); notably, there was a significant difference between group 4 and the remaining three groups but no significant difference between groups 1, 2 and 3. The f-CSA of the multifidus (cm2) was negatively correlated with age, with the f-CSA of the multifidus becoming more atrophic with increasing age; specifically, there was a significant difference between group 1 and the other three groups (P < 0.05) but not between groups 2, 3 and 4. Regarding the side of the herniated disc, (1) the differences in FF and f-CSA at the L4/5 and L5/S1 levels were not statistically significant between the affected side and the healthy side in patients with lumbar disc herniation at the L4/5 segment (P > 0.05); (2) the differences in FF and f-CSA at the L5/S1 level were not statistically significant between the affected side and the healthy side in patients with LDH at the L5/S1 segment (P > 0.05); (3) the difference between FF at the L4/5 level and f-CSA and FF at the L5/S1 level was not statistically significant (P > 0.05); and (4) the f-CSA at the L5/S1 level was significantly greater on the healthy side than on the affected side (P < 0.05).

CONCLUSION

The proportion of lipoatrophy in female patients with L4/5 and L5/S1 disc herniations was greater than that in male patients. Lipoatrophy of the multifidus muscle increased with age and was significantly worse in patients over 50 years of age. The f-CSA of the multifidus muscle was negatively related to age, and the f-CSA of the multifidus muscle became more atrophic with increasing age. A comparison of degeneration showed no significant difference between the L4/5 patients and the L5/S1 patients in terms of f-CSA atrophy on the affected side of the herniated disc compared to the healthy side.

Clinical Effectiveness of Single Lumbar Periradicular Infiltration in Patients with Sciatica

Periradicular therapy (PRT) is a minimally invasive radiological procedurein patients with chronic lumbar pain.The aim of the study is to identify clinical and radiological predictive factors for treatment success after a single PRT treatment in patients with sciatica.The study includes a prospective follow-up of 166 patients treated with PRT. The pain intensity is determined according to the VAS scale and the degree of improvement is presented as excellent (over 75%), good (50-70%), moderate (25-49%), and weak (less than 25%). The follow up of the treated patients was done at 2 weeks, 3 and 6 months. In patients with pain duration up to 3 months, the improvement was excellent in n=32 (58.18%) after 2 weeks, after 3 months n=41 (74.55%) and after 6 months n=41 (74.55%). This stands in contrast to patients with pain over 1 year. The percentage of improvement after 6 months, post-intervention, was highest in patients without nerve root compression (86.25±19.2),and the highest improvement after 6 months was in patients with localization of pain at the L4-L5 level (69.69±29.7), the greatest improvement after six months was in patients with extraforaminal hernia (62.82±34.3), and the lowest in patients with central stenosis (40.21±30.7).Our study results suggest that the shorter a pain duration, low-grade root compression, injection level and type of herniation area predictor the more favourable response patients have to transforaminal epidural steroid injection in patients with sciatica.

Moderate to Severe Multifidus Fatty Atrophy is the Risk Factor for Recurrence After Microdiscectomy of Lumbar Disc Herniation

OBJECTIVE

We attempted to investigate the potential risk factors of recurrent lumbar disc herniation (rLDH) after tubular microdiscectomy.

METHODS

We retrospectively analyzed the data of patients who underwent tubular microdiscectomy. The clinical and radiological factors were compared between the patients with and without rLDH.

RESULTS

This study included 350 patients with lumbar disc herniation (LDH) who underwent tubular microdiscectomy. The overall recurrence rate was 5.7% (20 of 350). The visual analogue scale (VAS) score and Oswestry Disability Index (ODI) at the final follow-up significantly improved compared with those preoperatively. There was no significant difference in the preoperative VAS score and ODI between the rLDH and non-rLDH groups, while the leg pain VAS score and ODI of the rLDH group were significantly higher than those of the non-rLDH group at final follow-up. This suggested that rLDH patients had a worse prognosis than non-rLDH patients even after reoperation. There were no significant differences in sex, age, body mass index, diabetes, current smoking and drinking, disc height index, sagittal range of motion, facet orientation, facet tropism, Pfirrmann grade, Modic changes, interdisc kyphosis, and large LDH between the 2 groups. Univariate logistic regression analysis revealed that rLDH was associated with hypertension, multilevel microdiscectomy, and moderate-severe multifidus fatty atrophy (MFA). A multivariate logistic regression analysis indicated that MFA was the sole and strongest risk factor for rLDH after tubular microdiscectomy.

CONCLUSION

Moderate-severe MFA was a risk factor for rLDH after tubular microdiscectomy, which can serve as an important reference for surgeons in formulating surgical strategies and the assessment of prognosis.

Comparison of efficacy according to voltage of pulsed radiofrequency treatment to lumbar dorsal root ganglion in patient with lumbar radiculopathy: Pilot study

BACKGROUND

Lumbar radicular pain (LRP) is a common symptom, but a challenging clinical problem. Pulsed radiofrequency (PRF) is a more recently developed technique that uses short pulses of radiofrequency current with intervals of longer pauses to prevent temperature from rising to the level of permanent tissue damage and has been advocated in treatment of such patients. But there were no comparative studies on the analgesic effects according to output voltage during PRF in patients with LRP. The goal of this study is to determine the clinical effect of high-voltage (60V) versus standard-voltage (45V) PRF of lumbar dorsal root ganglion.

METHODS/DESIGN

This study will be a prospective, double-blind randomized controlled pilot study. In this study, total 20 patients will be recruited and distributed equally into 2 groups: high-voltage (60V) PRF, low-voltage (45V) PRF. Outcomes will be radicular pain intensity; physical functioning; global improvement and satisfaction with treatment; and adverse events. The assessments will be performed at the 3-month follow-up period after the end of the treatments. The findings will be analyzed statistically considering a 5% significance level (P ≤ .05).

DISCUSSION

The results of this trial will help determine which voltage could be applied for PRF to dorsal root ganglion in LRP and be a basis for subsequent trials.

Prognostic factors associated with outcome following an epidural steroid injection for disc-related sciatica: a systematic review and narrative synthesis

PURPOSE

Clinical guidelines recommend epidural steroid injection (ESI) as a treatment option for severe disc-related sciatica, but there is considerable uncertainty about its effectiveness. Currently, we know very little about factors that might be associated with good or poor outcomes from ESI. The aim of this systematic review was to synthesise and appraise the evidence investigating prognostic factors associated with outcomes following ESI for patients with imaging confirmed disc-related sciatica.

METHODS

The search strategy involved the electronic databases Medline, Embase, CINAHL Plus, PsycINFO and reference lists of eligible studies. Selected papers were quality appraised independently by two reviewers using the Quality in Prognosis Studies tool. Between-study heterogeneity precluded statistical pooling of results.

RESULTS

3094 citations were identified; 15 studies were eligible. Overall study quality was low with all judged to have moderate or high risk of bias. Forty-two prognostic factors were identified but were measured inconsistently. The most commonly assessed prognostic factors were related to pain and function (n = 10 studies), imaging features (n = 8 studies), patient socio-demographics (n = 7 studies), health and lifestyle (n = 6 studies), clinical assessment findings (n = 4 studies) and injection level (n = 4 studies). No prognostic factor was found to be consistently associated with outcomes following ESI. Most studies found no association or results that conflicted with other studies.

CONCLUSIONS

There is little, and low quality, evidence to guide practice in terms of factors that predict outcomes in patients following ESI for disc-related sciatica. The results can help inform some of the decisions about potential prognostic factors that should be assessed in future well-designed prospective cohort studies.

Effect of concurrent aerobic exercise and bone marrow stromal cell transplantation on time-dependent changes of myogenic differentiation-related cascades in soleus muscle after sciatic nerve injury

The purpose of this study was to investigate the time-dependent alteration in whether concurrent aerobic exercise and bone marrow stromal cell (BMSC) engraftment could regulate myogenic differentiation-related signaling pathway in the soleus up to 35 days after sciatic nerve injury (SNI). The rats were divided as follows: the normal control (CON, n=5), sedentary group (SED, n=20), treadmill exercise group (TEX, n=20), BMSC transplantation group (BMSC, n=20), TEX+BMSC transplantation group (TEX+BMSC, n=20) 7, 14, 21, and 35 days after SNI. SNI was applied into the thigh and treadmill exercise was comprised of walking at a speed of 4 to 8 m/min for 30 min once a day. Harvested BMSC at a density of 5×10⁶ in 50-μL phosphate-buff-ered saline was injected into the injury site. Phosphorylated (p) extracellular signal-regulated kinase 1/2 expression was dramatically upregulated in BMSC and BMSC+EX groups from 21 days after SNI compared to those in the SED group. P-ribosomal s6 kinase (RSK) was sharply increased 14 days later, and then rapidly downregulated from day 21, whereas TEX, BMSC and TEX+ BMSC groups significantly kept up expression levels of p-RSK until 35 days post injury than SED group. TEX+BMSC group significantly increased activation of protein kinase B-mammalian target of rapamycin in the soleus from day 14 and myoblast determination protein 1-myogen-in pathways was activated in TEX+BMSC group from day 21. Present findings provide information that combined intervention of aerobic exercise and BMSC transplantation might be a reliable therapeutic strategy for overcoming the morphological and functional problems in denervated soleus muscle.

[The use of a fixed combination of diclofenac and orphenadrine in the treatment of acute pain syndrome in patients with discogenic lumbosacral radiculopathy and lumboischialgia]

Acute pain syndromes caused by discogenic lumbosacral radiculopathy and lumboischialgia are not uncommon in clinical practice and characterized by a high risk of becoming chronic. The pathogenetic aspects, features of the clinical picture, existing approaches to conservative treatment of these conditions are analyzed in this paper. Data on the efficacy and safety of a fixed combination of diclofenac and orphenadrine (Neodolpasse) use in the treatment of vertebrogenic pain syndromes based on the NEODOLEX study results are presented, and the authors' own clinical observations are given. Possible reasons for the high efficacy of Neodolpasse in patients with discogenic radiculopathies and nonspecific back and neck pain are discussed.

Biomechanics of Transforaminal Endoscopic Approaches

STUDY DESIGN

Biomechanical cadaveric study.

OBJECTIVE

The aim of this study was to compare the effect of transforaminal endoscopic approaches with open decompression procedures.

SUMMARY OF BACKGROUND DATA

Clinical studies have repeatedly highlighted the benefits of endoscopic decompression, however, the biomechanical effects of endoscopic approaches (with and without injury to the disk) have not been studied up to now.

MATERIALS AND METHODS

Twelve spinal segments originating from four fresh-frozen cadavers were biomechanically tested in a load-controlled endoscopic transforaminal approach study. Segmental range of motion (ROM) after endoscopic approach was compared with segmental ROM after (1) microsurgical decompression with unilateral laminotomy and (2) midline decompression with bilateral laminotomy. In the intact state and after decompression, the segments were loaded in flexion-extension (FE), lateral shear (LS), lateral bending (LB), anterior shear (AS), and axial rotation (AR).

RESULTS

Vertebral segment ROM was comparable between the two endoscopic transforaminal approaches. However, there was a-statistically nonsignificant-trend for a larger ROM after accessing via the inside-out technique: FE: +3% versus +7%, P =0.484; LS: +1% versus +12%, P =0.18; LB: +0.6% versus +9%, P =0.18; AS: +2% versus +11%, P =0.31; AR: -4% versus +5%, P =0.18. No significant difference in vertebral segment ROM was seen between the transforaminal endoscopic approaches and open unilateral decompression. Vertebral segment ROM was significantly smaller with the transforaminal endoscopic approaches compared with midline decompression for almost all loading scenarios: FE: +4% versus +17%, P =0.005; AS: +6% versus 21%, P =0.007; AR: 0% versus +24%, P =0.002.

CONCLUSION

The transforaminal endoscopic intracanal technique preserves the native ROM of lumbar vertebral segments and shows a trend toward relative biomechanical superiority over the inside-out technique and open decompression procedures.

Necessity of MRI-compatible deep brain stimulation systems - Hits and hints for decision making

OBJECTIVES

Deep brain stimulation (DBS) is a safe and effective treatment option for patients with movement disorders as Parkinson's disease, essential tremor and dystonia[1]. For many of these patients the need for imaging may arise in the following years after implantation. The study's aim was to get an overview of the amount of patients with a DBS system who needed an MRI after successful implantation, and if they did, whether the imaging led to a surgical consequence.

MATERIALS AND METHODS

In this retrospective descriptive work patients were included if they had their DBS implantation for at least 12 months at the time of analysis. Data were collected by retrospective analysis of the electronic patient files as well as a telephone interview. The reason of each imaging performed was assessed, if patients got MRI after the implantation, it was additionally recorded whether imaging led to a consequence (conservative treatment or surgery). An independent neurologist assessed if an MRI would have been better than a CT for the particular indication.

RESULTS

From 54 included patients, 28 patients received imaging after implantation, either CT or MRI. 7 patients underwent MRIs, of whom 3 patients received cranial MRIs and 4 patients received lumbar spine MRIs. All cranial MRIs led to conservative therapy, in 2 lumbar MRIs the diagnosis led to surgery. Nearly 13 % of the imaging performed in our study population occurred because of fall events, 9 of the included patients developed or have had a tumor diagnosis.

CONCLUSIONS

Safety of MRI for patients with implanted DBS-systems is and remains an important consideration. Since it can be assumed that patients at a younger age are more likely to get an MRI in the course of their disease, we suggest paying particular attention to the MRI's suitability of the DBS device by patients age. In the end it remains always an individual decision for the surgeon or the consulting physician, which system to use.

Platelet Rich Plasma and Platelet-Related Products in the Treatment of Radiculopathy-A Systematic Review of the Literature

Back pain with radicular symptoms is associated with detrimental physical and emotional functioning and economic burden. Conservative treatments including physical, pharmacologic and injection therapy may not provide clinically significant or long-standing relief. Regenerative medicine research including Platelet rich plasma (PRP), Platelet lysate (PL) or Plasma rich in growth factors (PRGF) continues to develop, however evidence appraisal for treatment of radicular pain remains lacking. Thus, we performed a systematic review to evaluate the effectiveness of epidural steroid injections containing PRP or related products to treat radicular pain. Embase, PubMed/MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar databases were queried. Twelve studies were included in qualitative analysis, consisting of three randomized controlled trials and nine observational studies. The primary outcome was pain intensity, and secondary outcomes included functional improvement, anatomical changes on advanced imaging, and adverse events. All studies identified improved pain intensity and functional outcomes after epidural injection of PRP, PRGF and/or PL. Similar or longer lasting pain relief was noted in the PRP cohort compared to the cohort receiving epidural steroid injections with effects lasting up to 12-24 months. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) analysis revealed a very-low certainty of evidence due to risk of bias, indirectness, and imprecision.

Knowledge and Attitude of Sciatica Pain and Treatment Methods among Adults in Saudi Arabia

Background. Sciatica is a relatively common condition, with a lifetime incidence varying from 13% to 40%. The corresponding annual incidence of an episode of sciatica ranges from 1% to 5%. The exact cause of sciatica is unknown to this day; treatment methods and practices differ between individuals based on their cultural background, socioeconomic status, and religious beliefs. This study aimed to assess the knowledge and attitude toward sciatica pain among adults in Saudi Arabia. Methods. A cross-sectional study was conducted among the adult population in Saudi Arabia. A self-administered questionnaire was distributed among the study population using an online survey. Questions were divided into four groups, each containing multiple questions covering the following aspects: demographic data, past medical history, and the assessment of knowledge and attitudes regarding sciatica. Results. A total of 3,764 respondents were involved in this study, with an age range of 18–65 years old (females 59.8%). The mean knowledge score was 3.8 (SD 2.1), with the majority having poor knowledge (60.1%). The most common source of sciatica information was an orthopedic or a neurosurgeon, while the most common self-treatment used was painkiller medications (30.8%). The mean attitude score was 35.8 (SD 5.3), with most respondents having a neutral attitude (80.3%). The factors correlated with an increase in knowledge and attitude were having a bachelor’s or higher degree and living in an urban area. Conclusion. While the attitude of the adult population toward sciatica pain seems adequate, their knowledge was shown to be deficient. Furthermore, when comparing diagnosed individuals living in cities with those in rural areas, both knowledge and attitudes were shown to be better in individuals living in cities. Awareness programs by health institutions and healthcare professionals are needed to enhance patients knowledge. Various media can be utilized to enhance patients knowledge including social media platforms.

Facet Joint Versus Transforaminal Epidural Steroid Injections in Patients With Cervical Radicular Pain due to Foraminal Stenosis: A Retrospective Comparative Study

BACKGROUND

A cervical transforaminal epidural (TFE) steroid injection is a useful treatment option for cervical radicular pain, but it carries a small risk of catastrophic complications. Several studies have reported that cervical facet joint (FJ) steroid injection can reduce cervical radicular pain through an indirect epidural spread. The aim of this retrospective comparative study was to evaluate the pain scores and functional disability in subjects receiving cervical FJ or TFE steroid injection for the treatment of cervical radicular pain due to foraminal stenosis (FS).

METHODS

We selected 278 patients 18 years of age and older who underwent cervical FJ (n = 130) or TFE (n= 148) steroid injection for cervical radicular pain. The primary outcomes included pain scores and functional disability during hospital visits one, three, and six months after the initial injection. Secondary outcomes were the proportion of responders and Medication Quantification Scale (MQS) scores. Adverse events and variables correlating with effectiveness one month after the initial injection were also evaluated.

RESULTS

The Numeric Rating Scale and Neck Disability Index scores showed a significant improvement one, three, and six months after the initial injection in both groups, with no significant differences between the groups. No significant differences were observed in the success rates of the procedure one, three, and six months after the initial injection for either group. There were no significant differences in MQS between the groups during the follow-up period. Univariate and multivariate logistic regression analyses revealed that the injection method, age, sex, number of injections, FS severity, MQS, pain duration, and the presence of cervical disc herniation were not independent predictors of treatment success.

CONCLUSION

The efficacy of FJ steroid injection may not be inferior to that of TFE steroid injection in patients with cervical radicular pain due to FS.

Relationship between herniated intervertebral disc fragment weight and pain in lumbar microdiscectomy patients

OBJECTIVE

The relationship between lumbar disc herniation (LDH) size and the severity of preoperative pain and its impact on postoperative recovery is incompletely understood. This study was conducted to investigate the association between herniated disc fragment weight and pain before and after microdiscectomy.

METHODS

A consecutive series of patients from an ongoing randomised controlled trial (ACTRN12616001360404) were included in this study. Included patients were aged between 18 and 75, had a clinical diagnosis of radiculopathy, and MRI evidence of a concordant single-level lumbar disc herniation. All patients underwent standard microdiscectomy without aggressive discectomy or curettage of the endplates. Disc fragment weight was measured intraoperatively.

RESULTS

A total of 122 patients with a mean age of 49.5 ± 12.8 years, were included. The median weight of disc fragment was 0.545 g (95% CI 0.364 - 0.654 g). There was no relationship between disc weight and the duration of symptoms (p = 0.409) severity of preoperative leg pain (p = 0.070) or preoperative back pain (p = 0.884). Disc fragment weight was demonstrated to have no correlation with clinically significant postoperative leg pain improvement (p = 0.535) or back pain (p = 0.991). Additional LDH factors, including radiological percentage of canal compromise (p = 0.714), herniation classification (p = 0.462), and vertebral level (p = 0.788) were also shown to have no effect on leg pain outcomes.

CONCLUSIONS

Disc fragment weight had no effect on the severity of pain at presentation or after microdiscectomy. Patients benefit from surgery equally, regardless of the size of LDH.

A case of severe sciatica caused by a lymphocele after renal transplantation

Background

Sciatica is commonly caused by lumbar spinal disease. However, it can also be caused by tumors, infectious diseases, or muscle entrapment. We present a case of sciatica caused by a lymphocele after renal transplantation.

Presentation

A 50-year-old man who had undergone renal transplantation presented with sciatica and low back pain without leg edema. The patient was diagnosed with lumbar disc herniation during the first medical examination. Regardless of the treatment, the symptoms were exacerbated and red flag signs of low back pain were observed. Compression of the sciatic nerve by the lymphocele was confirmed by computed tomography. The sciatica was improved by ethanol injection for the lymphocele.

Conclusions

We encountered a rare case of severe sciatica without edema caused by lymphocele after renal transplantation. Careful examination is required to make a different diagnosis of lymphocele from other lumbar spinal diseases.

Evaluation of Endoscopic Versus Open Lumbar Discectomy: A Multi-Center Retrospective Review Utilizing the American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) Database

Introduction: Endoscopic techniques in spine surgery continue to gain popularity due to their potential for decreased blood loss and post-operative pain. However, limited studies have evaluated these techniques within the United States. Additionally, given the limited number of practitioners with experience in endoscopy, most current studies are limited by a lack of heterogeneity.

Methods: The American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to evaluate the effect of endoscopic surgery on adverse events. Current Procedural Terminology (CPT) codes for open discectomy were compared with the relevant CPT codes for endoscopic lumbar discectomy. Baseline patient characteristics and adverse outcomes were then compared. 

Results: A total of 38,497 single-level lumbar discectomies were identified and included. Of these, 175 patients undergoing endoscopic discectomy were compared with 38,322 patients undergoing open discectomy. Endoscopic discectomy demonstrated a shorter operative time of 88.6 minutes than 92.1 minutes in the open group. However, this was not significant (p=0.08). Patients in the endoscopic group demonstrated a shorter total length of stay of 0.81 days vs 1.15 days (p=0.014). Total adverse events were lower in the endoscopic group at 0.6% vs 3.4% in the open group (p=0.03).

Conclusion: Endoscopic discectomy demonstrated a significantly lower rate of adverse events and shorter total length of stay than open discectomy. Further research is necessary over time to evaluate larger patient populations as this technology is more rapidly incorporated.

A Bioinformatics Study of Immune Infiltration-Associated Genes in Sciatica

Sciatica has been widely studied, but the association of sciatica with immune infiltration has not been studied. We aimed to screen key genes and to further investigate the impact of immune infiltration in patients with sciatica. The bioinformatics analyzes were performed based on the GSE150408 dataset. Subsequently, we used CIBERSORT to study the immune infiltration in the disease group. Results showed that 13 genes were with differentially expressions in the sciatica group compared to healthy participants, including 8 up-regulated and 5 down-regulated genes. Through the LASSO model and SVM-RFE analysis, a total of 6 genes have intersections, namely SLED1, CHRNB3, BEGAIN, SPTBN2, HRASLS2, and OSR2. The ROC curve area also confirmed the reliability of this method. CIBERPORT analysis showed that T cell gamma delta infiltration decreased and neutrophil infiltration increased in the disease group. Then the association of these six key genes with immune infiltration was further verified. We found six overlapping genes and found that they were closely associated with the total immune infiltration in the sciatic nerve disease group. These findings may provide new ideas for the diagnosis and therapeutics of patients with sciatica.

Low Back Pain With Persistent Radiculopathy; the Clinical Role of Genetic Variants in the Genes SOX5, CCDC26/GSDMC and DCC

In a recently published genome-wide association study (GWAS) chronic back pain was associated with three loci; SOX5, CCDC26/GSDMC and DCC. This GWAS was based on a heterogeneous sample of back pain disorders, and it is unknown whether these loci are of clinical relevance for low back pain (LBP) with persistent radiculopathy. Thus, we examine if LBP with radiculopathy 12 months after an acute episode of LBP with radiculopathy is associated with the selected single nucleotide polymorphisms (SNPs); SOX5 rs34616559, CCDC26/GSDMC rs7833174 and DCC rs4384683. In this prospective cohort study, subjects admitted to a secondary health care institution due to an acute episode of LBP with radiculopathy, reported back pain, leg pain, and Oswestry Disability Index (ODI), were genotyped and followed up at 12 months (n = 338). Kruskal-Wallis H test showed no association between the SNPs and back pain, leg pain or ODI. In conclusion, LBP with radiculopathy 12 months after an acute episode of LBP with radiculopathy, is not associated with the selected SNPs; SOX5 rs34616559, CCDC26/GSDMC rs7833174 and DCC rs4384683. This absent or weak association suggests that the SNPs previously associated with chronic back pain are not useful as prognostic biomarkers for LBP with persistent radiculopathy.

Therapeutic effect and safety of Tuina on sciatica: A protocol for systematic review and meta-analysis∗

BACKGROUND

Sciatica is one of the common pain symptoms in the human body, also known as radiating leg pain. Sciatica is increasingly occurring due to poor posture and lack of physical exercise all over the world. At present, many studies have indicated that Tuina can improve the clinical symptoms and functional status of sciatica. However, there is currently no relevant systematic review to evaluate and report this clinical scientific issue. Consequently, this study will conduct a meta-analysis on the effectiveness and safety of Tuina therapy for sciatica.

METHODS AND ANALYSIS

Randomized controlled trials (RCTs) related to Tuina treatment of sciatica will be retrieved from the Chinese and English databases and Clinical Trial Register. These databases include China National Knowledge Infrastructure, Wan Fang Database, Chinese Biomedical Literature Database, VIP Database for Chinese Technical Periodicals, PubMed, Embase, Web of Science, Cochrane Library, and Medline, etc. We will consider articles published in English or Chinese between database initiation and October 2021. Our team will use Review Manager Software 5.3 software provided by the Cochrane Collaborative Network to conduct this systematic review and meta-analysis.

RESULTS

This study provides a comprehensive evaluation of the effectiveness and safety of Tuina therapy for sciatica.

CONCLUSION

The conclusion of our study will provide scientific evidence and reference to determine whether Tuina is an effective and safe intervention for patients with sciatica.

REGISTRATION NUMBER

INPLASY2021100034.

Prevalence, Characteristics, Association Factors of and Management Strategies for Low Back Pain Among Italian Amateur Cyclists: an Observational Cross-Sectional Study

Background

Low back pain (LBP) is a burdensome problem affecting amateur cyclists. This cross-sectional study analysed Italian amateur cycling cohort’s demographic and sport-specific characteristics, the prevalence and characteristics of LBP among this population, its possible association factors, the management strategies adopted to deal with LBP and the sample’s beliefs among possible LBP triggers. A web-based cross-sectional survey was created. The questionnaire included 56 questions divided into six sections, querying the sample’s demographic, clinical, and cycling characteristics. Binomial logistic regression with a Wald backward method was performed to ascertain the effects of some covariates (“Sex”, “Age”, “Body Mass Index”, “Sleep hours”, “Work type”, “Cycling year”, “Number of training sessions per week”, “Stretching sessions”, “Being supervised by a coach or following a scheduled training”, “Other sports practised regularly”, “Number of cycling competitions per year”, “Past biomechanic visits”, “Specific pedal training”, “LBP before cycling”) on the likelihood of developing LBP in the last 12 months.

Results

A total of 1274 amateur cyclists answered the survey. The prevalence of LBP appeared to be 55.1%, 26.5% and 10.8% in life, in the last 12 months and the last 4 weeks, respectively. The final model of the logistic regression included the covariates “Sex”, “Work type”, “Cycling year”, “Being supervised by a coach or following a scheduled training”, “Other sports practised regularly”, “Specific pedal training”, “LBP before cycling”, among which “Cycling year” (variable “Between 2 and 5 years” vs. “Less than 2 years”, OR 0.48, 95% CI [0.26–0.89]), “Being supervised by a coach or following a scheduled training” (OR 0.53, 95% CI [0.37–0.74]), “Specific pedal training” (OR 0.69, 95% CI [0.51–0.94]), and “LBP before cycling” (OR 4.2, 95% CI [3.21–5.40]) were found to be significant.

Conclusions

The prevalence of LBP among Italian amateur cyclists seems to be less frequent compared to the general population. Moreover, undergoing previous specific pedal training and being supervised by a coach or following scheduled training drew a negative association with LBP development. This evidence highlights the importance of being overseen by specific sport figures that could offer a tailored evidence-based training to reach good physical level and to practise sports safely.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-021-00370-2.

Correlation Between Intravascular Injection Rate, Pain Intensity, and Degree of Cervical Neural Foraminal Stenosis During a Cervical Transforaminal Epidural Block

Purpose

Cervical transforaminal epidural blocks (CTEBs) are useful for the treatment of cervical radicular pain. However, during CTEBs, inadvertent intravascular injection can introduce particulate steroids into the bloodstream, thus leading to serious complications. Moreover, the risk factors associated with intravascular injection during CTEBs have not been identified. Cervical neural foraminal stenosis (CNFS) is a form of neural foraminal narrowing and a common cause of cervical radicular pain. In this study, we aimed to identify whether there is a correlation between the incidence of intravascular injection during CTEB, pain intensity, and the degree of CNFS.

Patients and Methods

A total of 126 patients were recruited. The patients were classified into two subgroups (group M and group S) based on the routine cervical T2-weighted axial magnetic resonance imaging (MRI) findings. Group M (n = 63) consisted of moderate CNFS patients, while group S (n = 63) consisted of severe CNFS patients. The occurrence of intravascular injection during CTEB was established using real-time fluoroscopy. The intravascular injection was determined by the spreading of the contrast medium through the vascular channel during the injection. Additionally, pain intensity was scored using a Numeric Rating Scale (NRS) before the procedure and 1 month after the procedure.

Results

There was no significant difference in the incidence of intravascular injection during CTEB between group M and group S (41.3% vs 39.7%, respectively; p = 0.99) and in the NRS scores before and 1 month after CTEB. However, both groups showed a significant decrease in the NRS scores at 1 month after the procedure compared with that before the procedure.

Conclusion

The degree of CNFS does not affect the incidence of intravascular injection during CTEB. Regardless of whether patients have moderate or severe CNFS, caution should be exercised during CTEB procedures.

Effectiveness and safety of motion style acupuncture treatment of the pelvic joint for herniated lumbar disc with radiating pain: A prospective, observational pilot study

CONTEXT

Conservative treatment is effective for treating and managing herniated lumbar disc with radiating leg pain.

OBJECTIVES

To investigate the effects of motion style acupuncture treatment (MSAT) on the pelvic joint for this condition.

DESIGN

This prospective observational study was a pilot study for a future randomized, controlled trial (RCT).

SETTING

[masked for review].

PATIENTS/INTERVENTIONS

We enroled 40 patients and allocated them to two groups (both n = 20). Groups 1 and 2 received integrative Korean medicine treatment (KMT) and integrative KMT with MSAT for pelvic joint, respectively. Primary outcome was the Numeric Rating Scale (NRS) score for low back pain. Secondary outcomes were the Oswestry Disability Index (ODI), Visual analogue Scale (VAS), and EuroQol 5-Dimension-5-level (EQ-5D-5 L) scores. Efficacy was assessed by comparing the baseline and Day 4 results. Safety was assessed based on the frequency and severity of all adverse events.

RESULTS

On Day 14, except for ODI in Group 1, the NRS, VAS, and EQ-5D-5 L scores showed significant improvements in both groups. On Day 90, both groups showed significant improvements in the NRS, ODI, and EQ-5D-5 L scores. There was a significant between-group difference in the NRS score on Day 7. On Day 14, Group 2 had a significantly lower VAS score for radiating leg pain than Group 1. Twelve patients reported adverse events associated with integrative KMT; however, there was no association with pelvic joint MSAT.

CONCLUSION

Adding MSAT for pelvic joint to conventional integrative KMT may ameliorate radiating leg pain and improve the quality of life.

Effects of One-Fifth, One-Third, and One-Half of the Bodyweight Lumbar Traction on the Straight Leg Raise Test and Pain in Prolapsed Intervertebral Disc Patients: A Randomized Controlled Trial

The prolapsed intervertebral disc (PIVD) at the lumbar spine is one of the most common causes of low back pain (LBP) affecting humans worldwide. Lumbar traction is widely used as a part of physiotherapeutic modalities for its treatment; however, reports on its effectiveness and dosage are conflicting. This study is aimed at comparing the acute effects of three traction forces on the straight leg raise (SLR) test and LBP intensity. A total of 45 (age 35.53 yrs., ±3.09) participants with 15 participants in each group were recruited for the study. Participants were divided into groups A, B, and C wherein traction forces equal to one-fifth, one-third, and one-half of their bodyweight were applied, respectively. SLR range of motion (ROM) and pain were examined before and immediately after the application of traction. Significant improvement was observed in SLR ROM in all three groups (p < 0.05). However, for pain, significant improvement (p < 0.05) was observed only in the group with one-half of bodyweight force. There was no significant difference (p > 0.05) between the three groups for both variables. All three forces were equally effective in immediately improving SLR ROM in patients suffering from lumbar PIVD; however, pain improvement was observed with one-half of bodyweight only.

Intrapelvic entrapment of sacral nerve roots by abnormal bundles of the piriformis muscle: description of an extra-spinal cause of sciatica and pudendal neuralgia

Piriformis syndrome is a well-known extra-spinal cause of sciatica characterized by the entrapment of the sciatic nerve by variant bundles of the piriformis muscles in the deep gluteal space. In this case series, we describe the entrapment of intrapelvic portions of the sacral nerve roots by a variant bundle of the piriformis muscle originating medially to the sacral foramina, the surgical technique for the laparoscopic treatment of this condition, and the outcomes of the first eight cases treated with this technique. Five female and three male patients presenting with sciatica, pudendal pain and lower urinary tract symptoms underwent a laparoscopic exploration of the intrapelvic portion of the sacral nerve roots and transection of the abnormal piriformis bundle. Surgical technique is demonstrated in the Supplementary Video. Clinical success was achieved in seven of the eight patients, with a reduction of pain numeric rating scale from 8.5 (±1.2; 7-10) pre-operatively to 2.1 (±2.6; 0-7), 1-year following surgery. In conclusion, entrapment of intrapelvic portions of the sacral nerve roots by variant bundles of the piriformis originating medially to the sacral foramina are an extraspinal cause of sciatica, which can be treated though a laparoscopic approach.

Safety of Epidural Steroid Injections for Lumbosacral Radicular Pain: Unmet Medical Need

OBJECTIVE

Epidural steroid injections (ESIs) are a commonly utilized treatment for lumbosacral radicular pain caused by intervertebral disc herniation or stenosis. Although effective in certain patient populations, ESIs have been associated with serious complications, including paralysis and death. In 2014, the US Food and Drug Administration (FDA) issued a safety warning on the risk of injecting corticosteroids into the epidural space. The aims of this article were to review the neurological complications associated with ESIs and to compare the formulations, safety, and effectiveness of commercially available corticosteroids given by transforaminal, interlaminar, or caudal injection.

METHODS

Serious adverse events associated with ESIs were identified by a search of the FDA Adverse Event Reporting System (FAERS) database. A MEDLINE search of the literature was conducted to identify clinical trials comparing the safety and effectiveness of nonparticulate and particulate corticosteroid formulations.

RESULTS

Neurological complications with ESIs were rare and more often associated with the use of particulate corticosteroids administered by transforaminal injection. Among the 10 comparative-effectiveness studies reviewed, 7 found nonparticulate steroids had comparable efficacy to particulate steroids, and 3 studies suggested reduced efficacy or shorter duration of effect for nonparticulate steroids.

DISCUSSION

The risk of complications for transforaminal ESI is greater with particulate corticosteroids. Nonparticulate corticosteroids, which are often recommended as first-line therapy, may have a short duration of effect, and many commercial formulations contain neurotoxic preservatives. The safety profile of ESIs may continue to improve with the development of safer, sterile formulations that reduce the risk of complications while maintaining efficacy.

EPIDURAL STEROID INJECTION IN HERNIATED DISC AND LUMBAR CANAL STENOSIS: IS IT JUST A PLACEBO?

ABSTRACT Objective To study the role of epidural steroid injection (ESI) in patients with lumbar disc herniation (LDH) and lumbar canal stenosis (LCS). ESIs are regularly used to support non-operative treatment for LBP, and our anecdotal impression is that a considerable proportion of patients report substantial pain relief after ESI. Methods One thousand consecutive patients (645 patients with LDH and 355 patients with LCS) who required ESI from January-August 2018 were included. All were given the same ESI, prepared with triamcinolone (80 mg), bupivacaine (0.25%, 4 ml) and normal saline (4 ml). Patients were evaluated using the numerical rating scale (NRS) immediately after the injection, after 7 days, and after 3 months. Results The mean NRS back-pain score of the LDH-group was reduced from 5 (range: 4-8) to 4 (range: 2-7) immediately after injection, 2 (range: 1-7) after 7 days and 2 (range: 1-7) after 3 months (p-value<0.001). The mean NRS back-pain score of the LCS-group was reduced from 5 (range: 4-8) to 4 (range: 2-7) immediately after injection, 2 (range: 1-7) after 7 days and 3 (range: 1-7) after 3 months (p-value <0.001). The mean NRS leg-pain score of the LDH group was reduced from 5 (range: 4-9) to 3 (range: 3-7) immediately after injection, 1 (range: 1-6) after 7 days and 2 (range: 1-7) after 3 months (p-value <0.001). The mean NRS leg-pain score of the LCS group was reduced from 5 (range: 4-9) to 4 (range: 3-7) immediately after injection, 3 (range: 1-7) after 7 days and 2 (range 1-6) after 3 months (p-value <0.001). Conclusion ESI causes statistically significant improvement in back and leg pain in patients with LDH and LCS. However, the short and medium-term efficacy of ESI in the LCS group was lower than in the LDH group. Level of evidence IV; Prospective hospital-based study.

Image-guided spinal injection for pain management

Radiculopathy and spinal pain are debilitating conditions affecting millions of people worldwide each year. While most cases can be managed conservatively with physiotherapy and nonsteroidal anti-inflammatory medications, minimally invasive corticosteroid injections are the mainstay intervention for those not responsive to conservative treatment. Historically, spinal injections were performed in the absence of imaging guidance; however, imaging modalities, in particular fluoroscopy and computer tomography (CT), have become the standard of care in performing most of these procedures. Under imaging guidance, operators can accurately confirm needle placement and safely target localised pathologies.

Alpha lipoic acid with pulsed radiofrequency in treatment of chronic lumbosacral radicular pain: A prospective, randomized study

BACKGROUND

The effect of adding alpha lipoic acid (ALA) to pulsed radiofrequency (PRF) for treatment of lumbar-sacral pain was evaluated.

OBJECTIVE

to evaluate the effect of using ALA as an adjuvant therapy with PRF for treatment of chronic lumbosacral radicular pain caused by herniated disc.

METHODS

One hundred twenty patients with lumbo-sacral radicular pain allocated into 2 groups. Group I: treated with PRF at 42°C for 120 seconds. Group II: treated as in group I, plus oral ALA 600 mg (Thiotacid 600 mg, EVA PHARMA, Egypt) three times per day (1800 mg/day) for 3 weeks then 600 mg once daily for 2 weeks. The lumbo-sacral radicular pain evaluated using the numerical rating pain score and Oswestry Disability Index.

RESULTS

Success rate was significantly higher in group II at 3 and 6 months after intervention. The median values of the numerical rating pain score and the Oswestry Disability Index were significantly lower in group II with no significant difference in Epworth Sleepiness Scale. No major complications were reported in both groups.

CONCLUSION

The current study supports the use of ALA with PRF on the dorsal root ganglion for treating lumbosacral radicular pain.

Spinal nerve signal intensity on Dixon T2-weighted water-only sequence: an important outcome predictor after lumbar transforaminal epidural injection

OBJECTIVES

To evaluate the role of Dixon T2-weighted water-fat separation technique in predicting the outcome of lumbar transforaminal epidural injections (TFESIs).

METHODS

Patients who underwent TFESI of a single spinal nerve within 3 months after magnetic resonance imaging (MRI) exam between August 2018 and April 2020 were identified. The patients were classified into positive or negative outcome groups based on the response to the TFESI procedure. Two musculoskeletal radiologists measured the signal intensity of the injected side spinal nerves, contralateral side spinal nerves, and subcutaneous fat on axial Dixon T2-weighted water-only images, and the diameter of spinal nerve on axial Dixon T2-weighted in-phase images of the pre-procedural MRI. The measured values of the injected side spinal nerves were compared between the two groups and with the contralateral side spinal nerve.

RESULTS

A total of 94 patients were included, 76 in the positive outcome group and 18 in the negative outcome group. The mean signal intensity and the nerve-to-fat signal ratio of the injected side spinal nerve were significantly higher in the positive outcome group than in the negative outcome group (793.78 vs. 679.19, p = 0.016; 4.21 vs. 3.28, p = 0.003). In the positive outcome group, the diameter of the spinal nerve was significantly higher on the injected side than on the contralateral side (6.91 mm vs. 6.37 mm, p = 0.016).

CONCLUSIONS

The mean signal intensity and the nerve-to-fat signal ratio of the spinal nerve on axial Dixon T2-weighted water-only images can help predict patient response to the TFESI.

KEY POINTS

• Applying the Dixon technique to lumbar spine MRI can help predict patient response to the TFESI procedure. • An increased nerve-to-fat signal ratio and mean spinal nerve signal intensity on axial Dixon T2-weighted water-only images predicted favorable TFESI outcomes.