Variation in eligibility criteria from studies of radiculopathy due to a herniated disc and of neurogenic claudication due to lumbar spinal stenosis: a structured literature review

Similar improvements in patient-reported outcomes for non-specific low back pain patients with and without lumbar spinal stenosis symptoms following a structured education and exercise therapy program

BACKGROUND

People with nonspecific low back pain (NSLBP) can also experience overlapping symptoms of lumbar spinal stenosis (LSS), but the impact on treatment outcomes is unknown. This study investigated differences in treatment outcomes for disability, back pain intensity, and leg pain intensity following an education and exercise therapy program for NSLBP patients with and without comorbid LSS symptoms.

METHODS

This was a longitudinal analysis of 655 Danish participants in the GLA:D® Back program; an education and exercise therapy program for people with persistent NSLBP. Participants were classified as having comorbid LSS symptoms based on self-report. Linear mixed models were used to assess differences in change in disability (Oswestry Disability Index [0-100]) and back and leg pain intensity (Numeric Rating Scale [0-10]) at 3-, 6-, and 12-months between those with and without LSS symptoms.

RESULTS

28% of participants reported LSS symptoms. No certain differences in change in disability or back pain intensity improvement were observed at any time-point between those with and without LSS symptoms. Participants with LSS symptoms had slightly greater improvement in leg pain intensity at 6- (-0.7, 95% CI -1.2 to -0.2) and 12-months (-0.6, 95% CI -1.2 to -0.1).

CONCLUSION

Compared to those without LSS symptoms, patients with persistent NSLBP and LSS symptoms can expect similar improvements in disability and back pain intensity, and slightly greater improvements in leg pain intensity with treatment. Therefore, education and exercise therapy programs designed for NSLBP are likely helpful for those also experiencing LSS symptoms.

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

ABSTRACT

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

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

STUDY DESIGN

Systematic review.

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Independent inter and intra-observer agreement of the Schizas's classification of degenerative lumbar stenosis: Comparison among three levels of surgical training

INTRODUCTION AND OBJECTIVES

Lumbar spinal stenosis is a common age-related condition that affects the quality of life. Multiple classifications have been developed to quantify the severity of stenosis affecting comparison between studies and homogenous communication among surgeons and researchers. Even though this classification has not shown a direct clinical correlation, Schizas's classification appears to be a simple method to assess stenosis. Our objective was to evaluate the inter and intraobserver independent agreement of the Schizas's classification to assess stenosis severity. Additionally, we aimed to compare agreement among three levels of training in spine surgery.

MATERIALS AND METHODS

An independent inter and intra observer agreement was conducted among junior, senior orthopedic residents and attending spine surgeons. Ninety lumbar levels from 30 patients were evaluated by 16 observers. Weighted kappa agreement was used.

RESULTS

Overall interobserver and intraobserver agreement was of 0.57 (95% CI=0.52-0.63) and 0.69 (0.55-0.79), respectively. Interobserver agreement according to level of training yielded values of 0.53 (0.46-0.60) for junior residents, 0.61 (0.54-0.67) for senior residents and 0.67 (0.59-0.74) for attendings. Intraobserver agreement was of 0.54 (0.48-0.60) for junior, 0.60 (0.55-0.66) for senior and 0.66 (0.60-0.72) for attendings.

CONCLUSION

The Schizas's classification showed moderate interobserver and substantial intraobserver agreement. Among attending surgeons, substantial inter and intraobserver agreement was observed. The classification allowed acceptable communication among trained spine surgeons.

Independent inter and intra-observer agreement of the Schizas's classification of degenerative lumbar stenosis: Comparison among three levels of surgical training

INTRODUCTION AND OBJECTIVES

Lumbar spinal stenosis is a common age-related condition that affects the quality of life. Multiple classifications have been developed to quantify the severity of stenosis affecting comparison between studies and homogenous communication among surgeons and researchers. Even though this classification has not shown a direct clinical correlation, Schizas's classification appears to be a simple method to assess stenosis. Our objective was to evaluate the inter and intraobserver independent agreement of the Schizas's classification to assess stenosis severity. Additionally, we aimed to compare agreement among three levels of training in spine surgery.

MATERIALS AND METHODS

An independent inter and intra observer agreement was conducted among junior, senior orthopedic residents and attending spine surgeons. Ninety lumbar levels from 30 patients were evaluated by 16 observers. Weighted kappa agreement was used.

RESULTS

Overall interobserver and intraobserver agreement was of 0.57 (95% CI=0.52-0.63) and 0.69 (0.55-0.79), respectively. Interobserver agreement according to level of training yielded values of 0.53 (0.46-0.60) for junior residents, 0.61 (0.54-0.67) for senior residents and 0.67 (0.59-0.74) for attendings. Intraobserver agreement was of 0.54 (0.48-0.60) for junior, 0.60 (0.55-0.66) for senior and 0.66 (0.60-0.72) for attendings.

CONCLUSION

The Schizas's classification showed moderate interobserver and substantial intraobserver agreement. Among attending surgeons, substantial inter and intraobserver agreement was observed. The classification allowed acceptable communication among trained spine surgeons.

Characteristics associated with comorbid lumbar spinal stenosis symptoms in people with knee or hip osteoarthritis: an analysis of 9,136 good life with osteoArthritis in Denmark (GLA:D®) participants

BACKGROUND

Previous studies have found that lumbar spinal stenosis (LSS) often co-occurs with knee or hip OA and can impact treatment response. However, it is unclear what participant characteristics may be helpful in identifying individuals with these co-occurring conditions. The aim of this cross-sectional study was to explore characteristics associated with comorbid symptoms of lumbar spinal stenosis (LSS) in people with knee or hip osteoarthritis (OA) enrolled in a primary care education and exercise program.

METHODS

Sociodemographic, clinical characteristics, health status measures, and a self-report questionnaire on the presence of LSS symptoms was collected at baseline from the Good Life with osteoArthritis in Denmark primary care program for knee and hip OA. Cross-sectional associations between characteristics and the presence of comorbid LSS symptoms were assessed separately in participants with primary complaint of knee and hip OA, using domain-specific logistic models and a logistic model including all characteristics.

RESULTS

A total of 6,541 participants with a primary complaint of knee OA and 2,595 participants with a primary complaint of hip OA were included, of which 40% and 50% reported comorbid LSS symptoms, respectively. LSS symptoms were associated with similar characteristics in knee and hip OA. Sick leave was the only sociodemographic variable consistently associated with LSS symptoms. For clinical characteristics, back pain, longer symptom duration and bilateral or comorbid knee or hip symptoms were also consistently associated. Health status measures were not consistently related to LSS symptoms.

CONCLUSION

Comorbid LSS symptoms in people with knee or hip OA undergoing a primary care treatment program of group-based education and exercise were common and associated with a similar set of characteristics. These characteristics may help to identify people with co-occurring LSS and knee or hip OA, which can be used to help guide clinical decision-making.

Magnetic Resonance Imaging Grading Systems for Central Canal and Neural Foraminal Stenoses of the Lumbar and Cervical Spines With a Focus on the Lee Grading System

Magnetic resonance imaging (MRI) is a standard imaging modality for diagnosing spinal stenosis, which is a common degenerative disorder in the elderly population. Standardized interpretation of spinal MRI for diagnosing and grading the severity of spinal stenosis is necessary to ensure correct communication with clinicians and to conduct clinical research. In this review, we revisit the Lee grading system for central canal and neural foraminal stenosis of the cervical and lumbar spine, which are based on the pathophysiology and radiologic findings of spinal stenosis.

Associations between comorbid lumbar spinal stenosis symptoms and treatment outcomes in 6,813 patients with knee or hip osteoarthritis following a patient education and exercise therapy program

Objective

People with knee or hip osteoarthritis (OA) can experience comorbid lumbar spinal stenosis (LSS), but the impact on treatment outcomes is unknown. The aim of this study was to investigate associations between comorbid LSS symptoms and changes in pain, function, and quality of life following a patient education and exercise therapy program.

Design

This was a longitudinal analysis of 6813 participants in the Good Life with osteoArthritis in Denmark (GLA:D®) program; a structured patient education and exercise therapy program for knee and hip OA. Participants were classified as having comorbid LSS symptoms based on self-report symptom items. Linear mixed models were used to assess differences in change in pain, function, and quality of life outcomes (0 worst to 100 best) at 3- and 12-month follow-up.

Results

15% and 23% of knee and hip OA participants had comorbid LSS symptoms, respectively. Knee participants with comorbid LSS symptoms had smaller improvement in pain at 3-months (-1.7, 95% CI -3.3 to -0.1) and hip participants with comorbid LSS symptoms had greater improvement in function at 3- (2.5, 95% CI 0.5 to 5.0) and 12-months (3.8, 95% CI 0.9 to 6.6), when compared to those without LSS symptoms. These differences were not clinically significant and no differences in other outcomes were observed.

Conclusion

Knee or hip OA patients with comorbid LSS symptoms should expect similar improvements in knee- or hip-related pain, function, and quality of life outcomes when undergoing a patient education and exercise therapy program compared to those without LSS symptoms.

The relationship between bone canal diameter and facet tropism in cases of lumbar spinal stenosis

Objectives

Lumbar spinal stenosis (LSS) is a condition that increases in frequency with the aging of the spine and has adverse effects on the quality of life of individuals. Facet tropism (FT) refers to the difference in the orientation of the facet joints relative to each other in the sagittal plane. This situation may be due to a developmental defect or different stimuli. In many biomechanical studies in the literature, the relationship between FT and lumbar degenerative disorders has been investigated. In this study, we aimed to investigate whether there is a relationship between anteroposterior bone canal diameter and FT in LSS cases.

Materials and Methods

We retrospectively evaluated the CT and T2-weighted axial and sagittal magnetic resonance imaging of the lumbar region of 100 LSS patients who were operated on in our clinic between 2015 and 2017. For each patient, the facet joint angles, the degree of FT, and the AP diameter of the spinal canal were determined.

Results

The cases were grouped according to FT types and no correlation was found between midsagittal bone spinal canal measurement and FT types. According to the results, no significant difference was found.

Conclusion

As a result, because of there is no relationship between midsagittal bone canal diameter and FT, we thought that FT may be both a part of the degenerative process and a congenital origin.

Large variation in participant eligibility criteria used in plantar heel pain research studies - a systematic review

Introduction

Variable eligibility criteria across studies on plantar heel pain may result in compromising the generalisability of meta-analyses when heterogeneity is not accounted for. We aimed to explore: (i) heterogeneity of participant eligibility criteria in studies that have investigated plantar heel pain, and (ii) associations between key eligibility criteria and the characteristics of the participants included in the study.

Methods

In this systematic review with narrative synthesis, we extracted participant eligibility criteria, and participants’ age, body mass index (BMI), symptom duration and pain level from published studies on plantar heel pain. We performed a content analysis of criteria and aligned overarching criteria to the International Classification of Functioning, Disability and Health (ICF). We pooled studies that used the same thresholds for participant eligibility criteria into sub-groups. We also pooled and reported studies that did not have any eligibility criteria for the quantitative characteristics to use their data for reference values and pooled studies that did not have any eligibility criteria for the characteristics as reference.

Results

Two hundred and fourteen articles were included. The most reported participant eligibility criteria (as aligned to the ICF) related to body structures/function and personal factors. Age, BMI, symptom duration and pain level were used with various ranges and/or thresholds across studies (age was reported in 23 different ways across 97 studies; BMI 7/13; symptom duration 14/100; and pain level 8/31). When eligibility criteria included thresholds close to the reference value of a participant characteristic, characteristics were associated with criteria (e.g., younger participants when an upper age threshold was used).

Conclusion

Participant eligibility criteria in studies on plantar heel pain vary widely; studies differed substantially in their use of quantitative thresholds. Participant characteristics of samples in studies were associated with the criteria used. This study emphasises a need for adjusting for participant heterogeneity in systematic reviews to improve their validity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-022-00573-0.

Prevalence of multimorbid degenerative lumbar spinal stenosis with knee or hip osteoarthritis: a systematic review and meta-analysis

Background

Musculoskeletal multimorbidity is common and coexisting lumbar spinal stenosis (LSS) with knee or hip osteoarthritis (OA) has been reported. The aim of this review was to report the prevalence of multimorbid degenerative LSS with knee or hip OA based on clinical and/or imaging case definitions.

Methods

Literature searches were performed in MEDLINE, EMBASE, CENTRAL, and CINAHL up to May 2021. Studies involving adults with cross-sectional data to estimate the prevalence of co-occurring LSS with knee or hip OA were included. Study selection, data extraction, and risk of bias assessment were performed independently by two reviewers. Results were stratified according to index and comorbid condition, and by case definitions (imaging, clinical, and combined).

Results

Ten studies from five countries out of 3891 citations met the inclusion criteria. Sample sizes ranged from 44 to 2,857,999 (median 230) and the mean age in the included studies range from 61 to 73 years (median 66 years). All studies were from secondary care or mixed settings. Nine studies used a combined definition of LSS and one used a clinical definition. Imaging, clinical, and combined case definitions of knee and hip OA were used. The prevalence of multimorbid LSS and knee or hip OA ranged from 0 to 54%, depending on the specified index condition and case definitions used. Six studies each provided prevalence data for index LSS and comorbid knee OA (prevalence range: 5 to 41%) and comorbid hip OA (prevalence range: 2 to 35%). Two studies provided prevalence data for index knee OA and comorbid LSS (prevalence range 17 to 54%). No studies reporting prevalence data for index hip OA and comorbid LSS were found. Few studies used comparable case definitions and all but one study were rated as high risk of bias.

Conclusions

There is evidence that multimorbid LSS with knee or hip OA occurs in people (0 to 54%), although results are based on studies with high risk of bias and surgical populations. Variability in LSS and OA case definitions limit the comparability of studies and prevalence estimates should therefore be interpreted with caution.

Review registration

PROSPERO (CRD42020177759).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05104-3.

Symptoms of lumbar spinal stenosis in people with knee or hip osteoarthritis or low back pain: a cross-sectional study of 10,234 participants in primary care

OBJECTIVE

The aims of this study were to evaluate: the proportion of people reporting symptoms associated with lumbar spinal stenosis (LSS) in primary care programs for knee or hip osteoarthritis (OA) or persistent low back pain (LBP) and; the prevalence of self-reported clinical LSS in these three cohorts, according to two sets of adapted criteria.

METHOD

A cross-sectional analysis of baseline data from the Good Life with osteoArthritis in Denmark primary care programs. Self-report LSS symptom questions were administered to participants with knee OA, hip OA, and persistent LBP. The prevalence of eleven LSS symptoms and clinical LSS were calculated for each cohort.

RESULTS

A total of 10,234 participants were included in the analysis. A similar proportion of participants in each cohort were female (69%), with a 6- and 7-year older mean age in the knee and hip cohorts compared to the back cohort. A greater proportion of participants with LBP reported LSS symptoms (range 11-71%) than in the hip (11-50%) and knee (8-40%) cohorts. This pattern was observed for all but one symptom. The same pattern was observed for the prevalence of clinical LSS with less than 10% of people in each cohort satisfying the clinical criteria.

CONCLUSION

Self-reported LSS symptoms are commonly reported by people treated in primary care for knee or hip OA, although not as frequently as reported by those with LBP. Despite symptoms of LSS being common, only a small proportion of people were classified as having self-reported clinical LSS.

Research Tendency in Lumbar Spinal Stenosis over the Past Decade: A Bibliometric Analysis

OBJECTIVE

The purpose of this bibliometric analysis was to identify trends and hot topics in research on lumbar spinal stenosis (LSS) over the past decade, for helping researchers explore new directions for future research in that area.

METHODS

All research articles on LSS, written in English and indexed in the Web of Science database (WoS) between 2010 and 2020, were used. The visualization of network and in-depth bibliometric analysis including the number of publications, countries, institutions, journals, authors, cited references, and key words was carried out with the help of CiteSpace.

RESULTS

A total of 4033 papers (3577 original articles and 476 reviews) were identified and included in the study. The most productive year was in 2019. The Spine was the journal that published the highest number of articles and received the most citations. The most productive country and institutions in this field were the United States and Seoul National University, respectively. Kim HJ was the most prolific author, and Deyo RA ranked the first in the cited authors. The most cited article was published in 2010 by Deyo et al. and described the complications and charges index for LSS. From the coword cluster analysis, there were 3 frontiers in lumbar spinal stenosis: intervention, outcomes, and pathogenesis.

CONCLUSIONS

We have summarized the literature on LSS in the past decade including publication information, country, institution, authors, and journal. Research on minimally invasive surgery, outcomes, and gene therapies in LSS will be hot topics in the future.

Spinal Manipulation for Subacute and Chronic Lumbar Radiculopathy: A Randomized Controlled Trial

OBJECTIVE

We evaluated the efficacy of spinal manipulation for the management of nonacute lumbar radiculopathy.

METHODS

In a university hospital we performed a randomized controlled trial with 2 parallel arms. Patients (n = 44) with unilateral radicular low back pain lasting more than 4 weeks were randomly allocated to manipulation and control groups. The primary outcome was the intensity of the low back pain on a visual analog scale. The secondary outcome was the Oswestry Disability Questionnaire score. We also measured spinal ranges of motion. The assessments were carried out at the baseline, immediately after intervention, and at 3 months' follow-up. All patients underwent physiotherapy. The manipulation group received three sessions of manipulation therapy 1 week apart. For manipulation, we used Robert Maigne's technique.

RESULTS

Both groups experienced a decrease in back and leg pain significantly (all P ≤ 0.003). However, only the manipulation group showed significantly favorable results in the Oswestry scores (P < 0.001), and the straight leg raise test (P = 0.001). All ranges of motion increased significantly with manipulation (all P < 0.001), but the control group showed favorable results only in right and left rotations and in extension (all P < 0.001). Between-group analyses showed significantly better outcomes for manipulation in all measurements (all P ≤ 0.009) with large effect sizes.

CONCLUSION

Spinal manipulation improves the results of physiotherapy over a period of 3 months for patients with subacute or chronic lumbar radiculopathy.

Stratified versus usual care for the management of primary care patients with sciatica: the SCOPiC RCT

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.

Degenerative Lumbar Spinal Stenosis

Degenerative lumbar spinal stenosis is the most frequent cause of low back pain and/or sciatica in the elderly patient. Epidemiology, pathophysiology, clinical manifestations and testing are reviewed in a wide current bibliographic investigation. The importance of the relationship between clinical presentation and imaging study, especially magnetic resonance imaging (MRI), is emphasized. Prior to treatment indication, it is necessary to identify the precise location of pain, as well as the differential diagnosis between neurological and vascular lameness. Conservative treatment combining medications with various physical therapy techniques solves the problem in most cases, while therapeutic testing with injections, whether epidural, foraminal or facetary, is performed when pain does not subside with conservative treatment and before surgery is indicated. Injections usually perform better results in relieving sciatica symptoms and less in neurological lameness. Equine tail and/or root decompression associated or not with fusion is the gold standard when surgical intervention is required. Fusion after decompression is necessary in cases with segmental instability, such as degenerative spondylolisthesis. When canal stenosis occurs at multiple levels and is accompanied by axis deviation, whether coronal and/or sagittal, correction of axis deviations should be performed in addition to decompression and fusion, especially of the sagittal axis, in which a lumbar lordosis correction is required with techniques that correct the rectified lordosis to values close to the pelvic incidence.

Steroids and L-Lysine Aescinate for Acute Radiculopathy Due to a Herniated Lumbar Disk

Background and objectives. The efficacy of commonly prescribed analgesic and adjuvant drugs for the management of patients with radiculopathy has not been well established. Oral steroids are commonly used to treat sciatica or radiculopathy due to a herniated disk but the effect remains controversial. L-lysine aescinate showed superiority over placebo or baseline therapy with NSAIDs alone in treating sciatica, but have not been evaluated in an appropriately powered clinical trial. Materials and Methods. Randomized, double-blind clinical trial conducted in two health centers in collaboration with Uzhhorod Natioanl University in Ukraine. Adults (N = 90) with acute radicular pain and a herniated disk confirmed by MRI were eligible. Participants were randomly assigned to three groups (N = 30 in each) to receive a baseline therapy with lornoxicam (16 mg per day) and adjunctive 5-day course of IV dexamethasone (first group: 8 mg per day/40 mg total) or 0,1% solution of L-lysine aescinate (5 mL and 10 mL for group 2 and 3 respectively). Primary outcomes were Visual Analogue Scale changes and the straight leg raise angle at 15th and 30th day. Results. The level of pain improvement at 15th days after initiation of therapy with dexamethasone or solution of L-lysine aescinate at doses of 5 or 10 mL was not significantly different. The lowest levels of pain were achieved in patients who received the L-lysine aescinate 10 mL, but the range of decrease in pain was slightly greater in the group administered dexamethasone. Conclusions. Among patients with acute radiculopathy due to a herniated lumbar disk a short course of IV dexamethasone or L-lysine aescinate resulted in pain improvement at 15th and 30th day. Dexamethasone may be preferable if a longer-term analgesic effect is needed. Taking into account side effects of dexamethasone, a solution of L-lysine aescinate can be used to relieve pain symptoms.

Redefining lumbar spinal stenosis as a developmental syndrome: does age matter?

OBJECTIVE

Age is commonly thought to be a risk factor in defining lumbar spinal stenosis (LSS) degenerative or developmental subtypes. This article is a follow-up to a previous article ("Redefining Lumbar Spinal Stenosis as a Developmental Syndrome: An MRI-Based Multivariate Analysis of Findings in 709 Patients Throughout the 16- to 82-Year Age Spectrum") that describes the radiological differences between developmental and degenerative types of LSS. MRI-based analysis of "degeneration" variables and spinal canal morphometric characteristics of LSS segments have been thought to correlate with age at presentation.

METHODS

The authors performed a re-analysis of data from their previously reported prospective MRI-based study, stratifying data from the 709 cases into 3 age categories of equal size (instead of the original < 60 vs ≥ 60 years). Relative spinal canal dimensions, as well as radiological degenerative variables from L1 to S1, were analyzed across age groups in a multivariate mode. The total degenerative scale score (TDSS) for each lumbar segment from L1 to S1 was calculated for each patient. The relationships between age and qualitative stenosis grades, TDSS, disc degeneration, and facet degeneration were analyzed using Pearson's product-moment correlation and multiple regression.

RESULTS

Multivariate analysis of TDSS and spinal canal dimensions revealed highly significant differences across the 3 age groups at L2-3 and L3-4 and a weaker, but still significant, association with changes at L5-S1. Age helped to explain only 9.6% and 12.2% of the variance in TDSS at L1-2 and L2-3, respectively, with a moderate positive correlation, and 7.8%, 1.2%, and 1.9% of the variance in TDSS at L3-4, L4-5, and L5-S1, respectively, with weak positive correlation. Age explained 24%, 26%, and 18.4% of the variance in lumbar intervertebral disc (LID) degeneration at L1-2, L2-3, and L3-4, respectively, while it explained only 6.2% and 7.2% of the variance of LID degeneration at L4-5 and L5-S1, respectively. Age explained only 2.5%, 4.0%, 1.2%, 0.8%, and 0.8% of the variance in facet degeneration at L1-2, L2-3, L3-4, L4-5, and L5-S1, respectively.

CONCLUSIONS

Age at presentation correlated weakly with degeneration variables and spinal canal morphometries in LSS segments. Age correlated with upper lumbar segment (L1-4) degeneration more than with lower segment (L4-S1) degeneration. The actual chronological age of the patients did not significantly correlate with the extent of degenerative pathology of the lumbar stenosis segments. These study results lend support for a developmental contribution to LSS.

Objective functional assessment using the “Timed Up and Go” test in patients with lumbar spinal stenosis

OBJECTIVE

Patient-reported outcome measures (PROMs) are standard of care for the assessment of functional impairment. Subjective outcome measures are increasingly complemented by objective ones, such as the “Timed Up and Go” (TUG) test. Currently, only a few studies report pre- and postoperative TUG test assessments in patients with lumbar spinal stenosis (LSS).

METHODS

A prospective two-center database was reviewed to identify patients with LSS who underwent lumbar decompression with or without fusion. The subjective functional status was estimated using PROMs for pain (visual analog scale [VAS]), disability (Roland-Morris Disability Index [RMDI] and Oswestry Disability Index [ODI]), and health-related quality of life (HRQoL; 12-Item Short-Form Physical Component Summary [SF-12 PCS] and the EQ-5D) preoperatively, as well as on postoperative day 3 (D3) and week 6 (W6). Objective functional impairment (OFI) was measured using age- and sex-standardized TUG test results.

RESULTS

Sixty-four patients (n = 32 [50%] male, mean age 66.8 ± 11.7 years) were included. Preoperatively, they reported a mean VAS back pain score of 4.1 ± 2.7, VAS leg pain score of 5.4 ± 2.7, RMDI of 10.4 ± 5.3, ODI of 41.9 ± 16.2, SF-12 PCS score of 32.7 ± 8.3, and an EQ-5D index of 0.517 ± 0.226. The preoperative rates of severe, moderate, and mild OFI were 4.7% (n = 3), 12.5% (n = 8), and 7.8% (n = 5), respectively, and the mean OFI T-score was 116.3 ± 23.7. At W6, 60 (93.8%) of 64 patients had a TUG test result within the normal population range (no OFI); 3 patients (4.7%) had mild and 1 patient (1.6%) severe OFI. The mean W6 OFI T-score was significantly decreased (103.1 ± 13.6; p < 0.001). Correspondingly, the PROMs showed a decrease in subjective VAS back pain (1.6 ± 1.7, p < 0.001) and leg pain (1.0 ± 1.8, p < 0.001) scores, disability (RMDI 5.3 ± 4.7, p < 0.001; ODI 21.3 ± 16.1, p < 0.001), and increase in HRQoL (SF-12 PCS 40.1 ± 8.3, p < 0.001; EQ-5D 0.737 ± 0.192, p < 0.001) at W6. The W6 responder status (clinically meaningful improvement) ranged between 81.3% (VAS leg pain) and 29.7% (EQ-5D index) of patients.

CONCLUSIONS

The TUG test is a quick and easily applicable tool that reliably measures OFI in patients with LSS. Objective tests incorporating longer walking time should be considered if OFI is suspected but fails to be proven by the TUG test, taking into account that neurogenic claudication may not clinically manifest during the brief TUG examination. Objective tests do not replace the subjective PROM-based assessment, but add valuable information to a comprehensive patient evaluation.

Redefining lumbar spinal stenosis as a developmental syndrome: an MRI-based multivariate analysis of findings in 709 patients throughout the 16- to 82-year age spectrum

OBJECTIVEUsing an imaging-based prospective comparative study of 709 eligible patients that was designed to assess lumbar spinal stenosis (LSS) in the ages between 16 and 82 years, the authors aimed to determine whether they could formulate radiological structural differences between the developmental and degenerative types of LSS.METHODSMRI structural changes were prospectively reviewed from 2 age cohorts of patients: those who presented clinically before the age of 60 years and those who presented at 60 years or older. Categorical degeneration variables at L1-S1 segments were compared. A multivariate comparative analysis of global radiographic degenerative variables and spinal dimensions was conducted in both cohorts. The age at presentation was correlated as a covariable.RESULTSA multivariate analysis demonstrated no significant between-groups differences in spinal canal dimensions and stenosis grades in any segments after age was adjusted for. There were no significant variances between the 2 cohorts in global degenerative variables, except at the L4-5 and L5-S1 segments, but with only small effect sizes. Age-related degeneration was found in the upper lumbar segments (L1-4) more than the lower lumbar segments (L4-S1). These findings challenge the notion that stenosis at L4-5 and L5-S1 is mainly associated with degenerative LSS.CONCLUSIONSIntegration of all the morphometric and qualitative characteristics of the 2 LSS cohorts provides evidence for a developmental background for LSS. Based on these findings the authors propose the concept of LSS as a developmental syndrome with superimposed degenerative changes. Further studies can be conducted to clarify the clinical definition of LSS and appropriate management approaches.

Dermatomal Versus Mixed Somatosensory Evoked Potentials in the Diagnosis of Lumbosacral Spinal Canal Stenosis

PURPOSE

The existing literature on the use of dermatomal somatosensory evoked potentials in lumbosacral spinal canal stenosis is limited. The goal of this study was to evaluate the role of dermatomal against mixed tibial somatosensory evoked potential (SEP) as a complementary procedure to imaging studies in the diagnosis of lumbosacral stenosis.

METHODS

Thirty patients with clinically and radiologically diagnosed lumbosacral stenosis and 20 normal individuals were enrolled in the study. The study was ethically approved, and informed consent for participation was provided. All participants underwent bilateral mixed tibial and dermatomal SEP study of the third (L3), fourth (L4), fifth lumbar (L5), and first sacral (S1) dermatomes. N45, N25, N20, and N10 tibial SEP waves were measured from four channels, whereas dermatomal waves were measured from cortical recording. Peak latency and amplitude of each wave were calculated.

RESULTS

The cutoff value of the dermatomal S1 latency showed the highest sensitivity and specificity percentages (81.7 and 82.5, respectively), followed by L5 and N25. N25-N45 interpeak latency showed the lowest sensitivity and specificity. All L5, S1, L4, and N25 latency cutoff values presented highly significant differences between affected sides and controls (P < 0.0001), followed by N45 and N20. The amplitude cutoff values of SEP waves showed equivocal sensitivity and specificity percentages.

CONCLUSIONS

Somatosensory evoked potential studies can be used as a supplementary test for the diagnosis of lumbosacral stenosis, with the dermatomal studies being more valuable expressing multiple root abnormalities. S1 dermatomal wave latency has the highest diagnostic value, followed by L5, N25, and then L4 latencies.

The Use of Imaging in Management of Patients with Low Back Pain

Lower back pain (LBP) is one of the most common chief complaints encountered in primary care. Advanced imaging studies, including computerized tomography (CT) and magnetic resonance imaging (MRI), are frequently ordered in the setting of LBP. Structural abnormalities are commonly identified by CT and MRI in patients complaining of low back pain, however, these findings are also found in asymptomatic patients. In the past decade, multiple guidelines have been published to help providers identify patients in whom the use of advanced imaging is appropriate. In this article, we review common conditions associated with LBP that require advanced imaging along with their clinical and associated imaging findings.

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

BACKGROUND CONTEXT

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

PURPOSE

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

STUDY DESIGN

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

PATIENT SAMPLE

Outpatients were recruited from spine clinics in five countries.

OUTCOME MEASURE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Safety and efficacy of neublastin in painful lumbosacral radiculopathy: a randomized, double-blinded, placebo-controlled phase 2 trial using Bayesian adaptive design (the SPRINT trial)

Neublastin (BG00010) is a first-in-class, glial cell-derived neurotrophic factor shown in preclinical studies and an early clinical trial to have potential for the treatment of neuropathic pain. SPRINT was a phase 2, multicenter, double-blinded, placebo-controlled study to evaluate efficacy/safety of 5 neublastin doses (50, 150, 400, 800, and 1200 μg/kg) administered as an intravenous injection 3 times/week for 1 week in patients with chronic painful lumbosacral radiculopathy, utilizing Bayesian response-adaptive study design. Primary endpoint was change from baseline in mean 24-hour average general pain intensity over a 5-day period (week 1) after the last dose, analyzed using a Bayesian normal dynamic linear model. One hundred seventy-six patients were randomized and received treatment (placebo n = 48, 50 μg/kg n = 38, 150 μg/kg n = 13, 400 μg/kg n = 16, 800 μg/kg n = 20, 1200 μg/kg n = 41). Among the tested neublastin doses, the lowest dose (50 μg/kg) showed the greatest difference from placebo for change from baseline in mean average general pain intensity at week 1 after last dose, followed by the highest dose (1200 μg/kg) (posterior mean difference -1.36 [95% credible interval -2.22 to -0.52] and -0.75 [-1.59 to 0.08], respectively). Similar trends were observed in secondary efficacy endpoints. The most common adverse event in all neublastin dose groups was pruritus (79% vs 10% with placebo). There was no dose-response relationship with respect to primary/secondary efficacy outcomes or incidence of pruritus, despite dose-proportional increases in serum neublastin concentrations. In conclusion, while this study showed some evidence of pain relief with neublastin, particularly at the lowest dose, there was no clear dose-response relationship for pain reduction or the most common adverse event of pruritus.

Clinical diagnostic model for sciatica developed in primary care patients with low back-related leg pain

BACKGROUND

Identification of sciatica may assist timely management but can be challenging in clinical practice. Diagnostic models to identify sciatica have mainly been developed in secondary care settings with conflicting reference standard selection. This study explores the challenges of reference standard selection and aims to ascertain which combination of clinical assessment items best identify sciatica in people seeking primary healthcare.

METHODS

Data on 394 low back-related leg pain consulters were analysed. Potential sciatica indicators were seven clinical assessment items. Two reference standards were used: (i) high confidence sciatica clinical diagnosis; (ii) high confidence sciatica clinical diagnosis with confirmatory magnetic resonance imaging findings. Multivariable logistic regression models were produced for both reference standards. A tool predicting sciatica diagnosis in low back-related leg pain was derived. Latent class modelling explored the validity of the reference standard.

RESULTS

Model (i) retained five items; model (ii) retained six items. Four items remained in both models: below knee pain, leg pain worse than back pain, positive neural tension tests and neurological deficit. Model (i) was well calibrated (p = 0.18), discrimination was area under the receiver operating characteristic curve (AUC) 0.95 (95% CI 0.93, 0.98). Model (ii) showed good discrimination (AUC 0.82; 0.78, 0.86) but poor calibration (p = 0.004). Bootstrapping revealed minimal overfitting in both models. Agreement between the two latent classes and clinical diagnosis groups defined by model (i) was substantial, and fair for model (ii).

CONCLUSION

Four clinical assessment items were common in both reference standard definitions of sciatica. A simple scoring tool for identifying sciatica was developed. These criteria could be used clinically and in research to improve accuracy of identification of this subgroup of back pain patients.

Lumbar spinal stenosis: symptoms, diagnosis and treatment (meta-analysis of literature data)

Lumbar spinal stenosis is a disease in which degenerated discs, ligamentum flavum, facet joints, while aging, lead to a narrowing of the space around the neurovascular structures of the spine. This article presents a meta-analysis of literature data on epidemiology, causes, pathogenesis, diagnosis and various types of treatment of lumbar spinal stenosis.

Decompressive surgery for lumbar spinal stenosis across the Atlantic: a comparison of preoperative MRI between matched cohorts from the US and Norway

BACKGROUND

There are no uniform guidelines regarding when to operate for Lumbar Spinal Stenosis (LSS). As we apply findings from clinical research from one population to the next, elucidating similarities or differences provides important context for the validity of extrapolating clinical outcomes. The aim of this study was to compare the morphological severity of lumbar spinal stenosis on preoperative MRI in patients undergoing decompressive surgery in Boston, USA, and Trondheim, Norway.

METHODS

In this observational retrospective study, we compared morphological severity on MRI before surgical treatment between two propensity score-matched patient populations with single or two-level symptomatic LSS. We assessed the radiographic severity of LSS utilizing the Schizas classification (grade A to D).

RESULTS

Following propensity score matching, demographics are balanced. In the Trondheim cohort, two levels decompression were present in 36.2% of the patients vs. 41.9% in Boston, (p = 0.396). There was no significant difference in grades A to D concerning central stenosis (p = 0.075). When dichotomized in mild/moderate (A/B) and severe /extreme (C/D), there were no significant differences in the rate of levels operated for high-grade stenosis (C/D), 67.6% in the Boston group compare to 78.1% in the Trondheim group (p = 0.088).

CONCLUSIONS

Trondheim, Norway, and Boston, US, have similar radiographic thresholds of LSS for offering surgery.

The Recent Trend in Diagnosis and Treatment of Chronic Low Back Pain

INTRODUCTION

Development of evidence-based medicine has made a big change in diagnosis and treatment of chronic low back pain. The recent trend is assessed through a review of literature.

METHODS

The articles published in these 10 years are reviewed, and important points are examined.

RESULTS

In diagnosis, challenges for history taking and limit of imaging or clinical guidelines are revealed. In treatment, cognitive behavioral treatment and exercises are proved effective. Sleep disturbance has recently attracted attention as a factor associated with low back pain. Cost-effectiveness of diagnosis and treatment modalities has come to be emphasized.

CONCLUSIONS

Diagnosis and treatment of chronic low back pain have been significantly changing. Multidisciplinary and multidimensional approach is essential. Chronic low back pain should be treated as a total pain, not a local pain.

Characteristics and determinants of clinical symptoms in radiographic lumbar spinal stenosis in a tertiary health care centre in sub-Saharan Africa

BACKGROUND

Lumbar spinal stenosis (LSS) refers to narrowing of the lumbar central spinal canal, lateral recess, and/or neuro-foramina. Radiographic LSS plays an important role in clinical LSS but is not solely accountable for the presence of symptoms. We sought to characterise clinical LSS and to determine factors associated with presence of symptoms of LSS in patients with radiographic LSS in a sub Saharan Africa setting.

METHODS

After prior ethical clearance, a case control study was done in a tertiary hospital in Douala-Cameroon, including 105 patients with radiographic LSS: 57 with symptoms of LSS (cases) and 58 with no symptoms (controls). Spinal stenosis was assessed using computed tomography (CT) scans. Data were analysed using SPSS version 23.

RESULTS

The mean age of our study participants was 53.4 ± 13.1 years. The mean age of onset of symptoms of LSS was 50.3 ± 11.6 years and the most common symptoms were Low back pain (100.0%), radicular symptoms (98.2%) and neurogenic claudication (98.2%). Obesity (p < 0.001) and a high waist circumference (p = 0.002) were significantly associated with presence of LSS symptoms in persons with radiographic LSS. After adjusting for body mass index, a positive family history of low back pain (p = 0.004), vertebra lesion at L2 (p = 0.034), L3 (p = 0.002), L4 (p = 0.025) and multiple (p = 0.008) levels, degenerative disc protrusion (p = 0.044), disc lesion at L3-L4 (p = 0.001), L4-L5 (p = 0.011) and multiple (p = 0.046) levels were significantly associated with presence of symptoms of LSS in persons with radiographic LSS.

CONCLUSION

Characteristics of clinical LSS have been described in this sub-Saharan Africa population. Obesity, a high waist circumference and a positive family history of low back pain are significantly associated with presence of symptoms of LSS in persons with radiographic LSS.

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

BACKGROUND CONTEXT

Classification criteria are recommended for diseases that lack specific biomarkers to improve homogeneity in clinical research studies. Because imaging evidence of lumbar disc herniations (LDHs) may not be associated with symptoms, clinical classification criteria based on patient symptoms and physical examination findings are required.

PURPOSE

This study aimed to produce clinical classification criteria to identify patients with radicular pain caused by LDH.

STUDY DESIGN

The study design was a two-stage process. Phase 1 included a Delphi process and Phase 2 included a cohort study.

PATIENT SAMPLE

The patient sample included outpatients recruited from spine clinics in five countries.

OUTCOME MEASURES

The outcome measures were items from history and physical examination.

MATERIALS AND METHODS

In Phase 1, 17 spine experts participated in a Delphi process to select symptoms and signs suggesting radicular pain caused by LDH. In Phase 2, 19 different clinical experts identified patients they confidently classified as presenting with (1) radicular pain caused by LDH, (2) neurogenic claudication (NC) caused by lumbar spinal stenosis, or (3) non-specific low back pain (NSLBP) with referred leg pain. Patients completed survey items and specialists documented examination signs. A score to predict radicular pain caused by LDH was developed based on the coefficients of the multivariate model. An unrestricted grant of less than US$15,000 was received from MSD: It was used to support the conception of the Delphi, data management, and statistical analysis. No fees were allocated to participating spine specialists.

RESULTS

Phase 1 generated a final list of 74 potential symptoms and signs. In Phase 2, 209 patients with pain caused by LDH (89), NC (63), or NSLBP (57) were included. Items predicting radicular pain caused by LDH (p<.05) were monoradicular leg pain distribution, patient-reported unilateral leg pain, positive straight leg raise test <60° (or femoral stretch test), unilateral motor weakness, and asymmetric ankle reflex. The score had an AUC of 0.91. An easy-to-use weighted set of criteria with similar psychometric characteristics is proposed (specificity 90.4%, sensitivity 70.6%).

CONCLUSIONS

Classification criteria for identifying patients with radicular pain caused by LDH are proposed. Their use could improve the homogeneity of patients enrolled in clinical research studies.

Value of a new pathological classification of lumbar intervertebral disc herniation based on transforaminal endoscopic observations

Removal of herniated disc materials based on an imaging only method may not relieve symptoms in many patients. Therefore, the aim of the present study was to develop a transforaminal endoscopic method of classifying the pathological type of lumber intervertebral disc herniation and to compare the outcomes of surgery based on the pathological type with those of conventional endoscopic disc removal. The records of patients who received endoscopic transforaminal nucleotomy with foraminoplasty for symptomatic lumbar disc herniation between 2009 and 2013 were retrospectively reviewed. Patients were then divided into two groups: Group A, which consisted of 275 patients who received conventional endoscopic transforaminal nucleotomy with foraminoplasty between 2009 and 2011 and group B, which consisted of 316 patients who received ‘targeted’ endoscopic transforaminal nucleotomy with foraminoplasty between 2011 and 2013 (based on the pathological type of disc herniation identified at surgery, including fresh, calcified and scar type based on intraoperative observations). The results showed that there were no significant differences in age, gender, body mass index, symptom duration, operated segments or previous invasive therapies between the two groups. Moreover, evaluation of visual analogue scale pain scores and Oswestry disability index scores revealed that the patients in group B had a greater improvement in symptoms than those in group A (P<0.05). In addition, an age >40 years and a longer symptom duration were associated with the calcified type, and previous invasive therapy was associated with the scar type. Therefore, specific surgical treatment based on the transforaminal endoscopic pathological type can result in better outcomes for patients with lumbar disc herniation.

Degenerative lumbar spinal canal stenosis: intra- and inter-reader agreement for magnetic resonance imaging parameters

PURPOSE

To assess the inter- and intra-reader agreement of commonly used quantitative and qualitative image parameters for the assessment of degenerative lumbar spinal canal stenosis (LSS) by magnetic resonance imaging (MRI).

METHODS

In this ethical board approved cross-sectional multicenter study, MRI of 100 randomly selected patients (median age 72.5 years, 48 % female) of the prospective Lumbar Stenosis Outcome Study (LSOS) were evaluated by two independent readers. A set of five previously published core imaging parameters as well as nine qualitative and five quantitative additional parameters regarding LSS and degenerative changes of the lumbar spine were assessed to calculate κ and intraclass correlation coefficients (ICC) for the inter-reader agreement. Additional repeated image evaluations were performed by one reader to calculate the intra-reader agreement.

RESULTS

κ values for the core image parameters ranged between 0.42 (compromise of the foraminal zone) and 0.77 (relation between fluid and cauda equina) for inter-reader agreement and between 0.59 (compromise of the foraminal zone) and 0.8 (compromise of the central zone) for intra-reader agreement. The inter-reader agreement for the non-core parameters showed κ values of 0.27-0.69 and ICC values of 0.46-0.85. The intra-reader agreement showed κ values of 0.53-0.69 and ICC values of 0.81-0.88.

CONCLUSIONS

The inter- and intra-reader agreement of commonly used quantitative and qualitative image parameters for the assessment of LSS showed quite a variability with previously defined core parameters having good to excellent inter- and intra-reader agreements.

Classification of patients with low back-related leg pain: a systematic review

BACKGROUND

The identification of clinically relevant subgroups of low back pain (LBP) is considered the number one LBP research priority in primary care. One subgroup of LBP patients are those with back related leg pain. Leg pain frequently accompanies LBP and is associated with increased levels of disability and higher health costs than simple low back pain. Distinguishing between different types of low back-related leg pain (LBLP) is important for clinical management and research applications, but there is currently no clear agreement on how to define and identify LBLP due to nerve root involvement. The aim of this systematic review was to identify, describe and appraise papers that classify or subgroup populations with LBLP, and summarise how leg pain due to nerve root involvement is described and diagnosed in the various systems.

METHODS

The search strategy involved nine electronic databases including Medline and Embase, reference lists of eligible studies and relevant reviews. Selected papers were appraised independently by two reviewers using a standardised scoring tool.

RESULTS

Of 13,358 initial potential eligible citations, 50 relevant papers were identified that reported on 22 classification systems. Papers were grouped according to purpose and criteria of the classification systems. Five themes emerged: (i) clinical features (ii) pathoanatomy (iii) treatment-based approach (iv) screening tools and prediction rules and (v) pain mechanisms. Three of the twenty two systems focused specifically on LBLP populations. Systems that scored highest following quality appraisal were ones where authors generally included statistical methods to develop their classifications, and supporting work had been published on the systems' validity, reliability and generalisability. There was lack of consistency in how LBLP due to nerve root involvement was described and diagnosed within the systems.

CONCLUSION

Numerous classification systems exist that include patients with leg pain, a minority of them focus specifically on distinguishing between different presentations of leg pain. Further work is needed to identify clinically meaningful subgroups of LBLP patients, ideally based on large primary care cohort populations and using recommended methods for classification system development.

Management of lumbar spinal stenosis

Lumbar spinal stenosis (LSS) affects more than 200,000 adults in the United States, resulting in substantial pain and disability. It is the most common reason for spinal surgery in patients over 65 years. Lumbar spinal stenosis is a clinical syndrome of pain in the buttocks or lower extremities, with or without back pain. It is associated with reduced space available for the neural and vascular elements of the lumbar spine. The condition is often exacerbated by standing, walking, or lumbar extension and relieved by forward flexion, sitting, or recumbency. Clinical care and research into lumbar spinal stenosis is complicated by the heterogeneity of the condition, the lack of standard criteria for diagnosis and inclusion in studies, and high rates of anatomic stenosis on imaging studies in older people who are completely asymptomatic. The options for non-surgical management include drugs, physiotherapy, spinal injections, lifestyle modification, and multidisciplinary rehabilitation. However, few high quality randomized trials have looked at conservative management. A systematic review concluded that there is insufficient evidence to recommend any specific type of non-surgical treatment. Several different surgical procedures are used to treat patients who do not improve with non-operative therapies. Given that rapid deterioration is rare and that symptoms often wax and wane or gradually improve, surgery is almost always elective and considered only if sufficiently bothersome symptoms persist despite trials of less invasive interventions. Outcomes (leg pain and disability) seem to be better for surgery than for non-operative treatment, but the evidence is heterogeneous and often of limited quality.

Is There an Association Between Radiological Severity of Lumbar Spinal Stenosis and Disability, Pain, or Surgical Outcome?: A Multicenter Observational Study

STUDY DESIGN

Observational multicenter study.

OBJECTIVE

To evaluate if the severity of lumbar spinal stenosis (LSS) on magnetic resonance imaging (MRI) correlates with preoperative disability, pain, or surgical outcomes.

SUMMARY OF BACKGROUND DATA

Surgeons use the morphological appearance of LSS on MRI for clinical decision making. However, the associations between radiological severity of LSS and disability, pain, or surgical outcomes remain unclear.

METHODS

Evaluation of severity of LSS on preoperative MRI according to the Schizas morphological classification. Patient and treatment data were retrieved from the Norwegian Registry for Spine Surgery. Preopertaive outcome measures were Oswestry disability index (ODI) and numeric rating scale (NRS) scores for back and leg pain. Postopertive outcome measures were ODI and NRS scores for back and leg pain at 1 year, changes in ODI and NRS scores after treatment, duration of surgery, length of hospital stay, and perioperative complications.

RESULTS

Of 202 patients included, 7 were found to have mild stenosis, 38 had moderate stenosis, 108 had severe stenosis, and 49 had extreme stenosis. The radiological severity of LSS was not linked to preoperative ODI (P = 0.089), NRS back pain (P = 0.273), or NRS leg pain (P = 0.282) scores. There were no differences in ODI (P = 0.933), NRS back pain (P = 0.652), or NRS leg pain (P = 0.912) scores after 1 year. The radiological severity of stenosis was not associated with change in ODI (P = 0.494), NRS back pain (P = 0.235), NRS leg pain (P = 0.790), duration of surgery (P = 0.661), length of hospital stay (P = 0.739), or perioperative complication rates (P = 0.467).

CONCLUSION

Among patients who underwent decompressive surgery for LSS, radiological severity of stenosis was not associated with preoperative disability and pain, or clinical outcomes 1 year after surgery. In this patient group, the radiological severity of LSS has no clear clinical correlation and should therefore not be overemphasized in clinical decision making.

LEVEL OF EVIDENCE

2.

Role of the Self-Administered, Self-Reported History Questionnaire to Identify Types of Lumbar Spinal Stenosis: A Sensitivity Analysis

Study Design

Case-control design.

Purpose

To evaluate the role of the self-administered, self-reported history questionnaire (SSHQ) in identifying types of lumbar spinal stenosis (LSS).

Overview of Literature

Diagnosis of types of LSS is controversial.

Methods

A total of 235 patients with LSS were asked to respond to the SSHQ. All of these patients recovered following surgical treatment. The classification of LSS patients was based on history, physical examinations, and imaging studies. It is considered to be the gold standard. Radicular and neurogenic claudication types of LSS were based on the SSHQ developed by Konno et al. Two categories of LSS were determined based on the SSHQ tool and gold standard. Finally, a sensitivity analysis was carried out to evaluate the diagnostic value of the SSHQ.

Results

The mean age of patients was 59.4 years. According to the criteria for gold standard, patients were diagnosed with the radicular type (n=103), and neurogenic claudication type (n=132). The questionnaire had desirable sensitivity, specificity, and accuracy in categorizing the two types of LSS: 97.8%, 66.6%, and 96.8% for the radicular type, and 97.0%, 80.0%, and 95.7% for the neurogenic claudication type.

Conclusions

Our findings indicate that the SSHQ is a reliable and a valid measure and it may be a clinical diagnosis support tool for identifying patients with two types of LSS.

Kirschner wire is more effective than the nerve root retractor in treating patients with disc herniation

OBJECTIVE

To investigate the value of using Kirschner wire in the intraspinal procedures.

METHODS

From May 2011 to October 2013, a total of 46 patients with a single-level lumbar disc herniation with concomitant lumbar instability were randomly assigned to two groups at the time of admission. Group 1 had 23 patients who underwent posterior lumbar fusion using a nerve root retractor to drag nerve root, and Group 2 also had 23 patients who underwent the same operation by fixing Kirschner wires in the vertebral body to drag nerve root. All of these patients were assessed with visual analog scales (VAS) and Japanese Orthopaedic Association (JOA) scores before surgery, and were followed up at the time points of one week (VAS score only), three, six, and twelve months respectively after surgery. The actual retraction time of the nerve root of each patient was also recorded during the operation.

RESULTS

The differences in VAS and JOA scores were not significant between Group 1 and 2 before surgery. However, these scores showed significant improvement in Group 2 at one week and three months after surgery compared with those in Group 1. At six and twelve month follow-up time points, no significant difference was observed between these two groups. However, the retraction time of the nerve root of the patients in Group 2 was significantly shorter than in Group 1.

CONCLUSIONS

Using Kirschner wires instead of the nerve root retractor to pull nerve root in the patients with a single-level lumbar disc herniation accompanied by the lumbar instability is more effective in reducing the dragging damage of the nerve root at early phases after surgery and in shortening retraction time.

Report of the NIH Task Force on Research Standards for Chronic Low Back Pain

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific, and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. The NIH Pain Consortium therefore charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimal data set to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The RTF believes these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. We expect the RTF recommendations will become a dynamic document, and undergo continual improvement.

PERSPECTIVE

A Task Force was convened by the NIH Pain Consortium, with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimal dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.

Neuropathic Pain Components in Patients with Lumbar Spinal Stenosis

PURPOSE

To determine the prevalence and characteristics of neuropathic pain (NP) in patients with lumbar spinal stenosis (LSS) according to subgroup analysis of symptoms.

MATERIALS AND METHODS

We prospectively enrolled subjects with LSS (n=86) who were scheduled to undergo spinal surgery. The patients were divided into two groups according to a chief complaint of radicular pain or neurogenic claudication. We measured patient's pain score using the visual analog scale (VAS), Oswestry Disability Index (ODI) and Leads Assessment of Neuropathic Symptoms and Signs (LANSS). According to LANSS value, the prevalence of NP component pain in patients with LSS was assessed. Statistical analysis was performed to find the relationship between LANSS scores and the other scores.

RESULTS

From our sample of 86 patients, 31 (36.0%) had a NP component, with 24 (63.4%) in the radicular pain group having NP. However, only seven patients (15.6%) in the neurogenic claudication group had NP. The LANSS pain score was not significantly correlated with VAS scores for back pain, but did correlate with VAS scores for leg pain (R=0.73, p<0.001) and with ODI back pain scores (R=0.54, p<0.01).

CONCLUSION

One-third of the patients with LSS had a NP component. The presence of radicular pain correlated strongly with NP. The severity of leg pain and ODI score were also closely related to a NP component. This data may prove useful to understanding the pain characteristics of LSS and in better designing clinical trials for NP treatment in patients with LSS.

Report of the NIH Task Force on research standards for chronic low back pain

OBJECTIVE

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific, and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus.

DESIGN

Expert panel and preliminary evaluation of key recommendations.

METHODS

The NIH Pain Consortium charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel developed a 3-stage process, each with a 2-day meeting.

RESULTS

The panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimal data set to describe research subjects (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals.

CONCLUSION

The RTF believes these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes. We expect the RTF recommendations will become a dynamic document, and undergo continual improvement.

PERSPECTIVE

A task force was convened by the NIH Pain Consortium with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimum dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.

Measuring spinal canal size in lumbar spinal stenosis: description of method and preliminary results

BACKGROUND

Lumbar spinal stenosis is a pathological condition of the spinal channel with its concentric narrowing with presence of specific clinical syndrome. Absence of the clear unified radiological signs is the one of the basic problems of the lumbar spinal stenosis.

PURPOSE

The authors seek to create method of assessment of the spinal canal narrowing degree, based on anatomical aspects of lumbar spinal stenosis.

STUDY DESIGN

Development of diagnostic criteria based on analysis of a consecutive patients group and a control group.

METHODS

Thirty seven patients (73 stenotic segments) with mean age 62,4 years old were involved in the study. Severity of clinical symptoms has been estimated by the measuring scales: Oswestry Disability Index (ODI) and Swiss Spinal Stenosis Questionnaire (SSQ). Mean number of the stenotic segments was 1.97. For all patients 8 radiological criteria have been measured. In the control group have been included 37 randomly selected patients (volunteers) in mean age of 53,4 years old without stenosis signs and narrowing of the spinal canal on the MRI imaging (73 segments total). Measurements were performed at the middle of intervertebral disc and facet joints level.

RESULTS

For description of the state of spinal canal we offer the coefficient: ratio of the lateral canals total area to the cross-sectional area of the dural sac ("coefficient of stenosis"). Comparison of mean values of "coefficient of stenosis" for main and control groups showed statistically significant differences (t = -12,5; p < 0.0001). Strong statistically significant correlation with the ODI and SSS scales was revealed for the obtained coefficient (p <0.05).

CONCLUSIONS

In our study new method of assessment of the spinal canal narrowing degree has been applied. Promising results have been obtained in a small group of patients. It is necessary to check the data on a large sample of recommendations for its clinical application.

Report of the NIH Task Force on research standards for chronic low back pain

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. Therefore, NIH Pain Consortium charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum dataset to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. We expect that the RTF recommendations will become a dynamic document and undergo continual improvement.

PERSPECTIVE

A task force was convened by the NIH Pain Consortium with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimum dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.

Focus article: report of the NIH Task Force on Research Standards for Chronic Low Back Pain

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. Therefore, NIH Pain Consortium charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum dataset to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. We expect that the RTF recommendations will become a dynamic document and undergo continual improvement.

PERSPECTIVE

A task force was convened by the NIH Pain Consortium with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimum dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.