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Jin Q, Chang Y, Lu C, Chen L, Wang Y. Referred pain: characteristics, possible mechanisms, and clinical management. Front Neurol 2023; 14:1104817. [PMID: 37448749 PMCID: PMC10338069 DOI: 10.3389/fneur.2023.1104817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 06/12/2023] [Indexed: 07/15/2023] Open
Abstract
Purpose of this review Referred pain is a common but less understood symptom that originates from somatic tissues. A comprehensive recognition of referred pain is important for clinicians when dealing with it. The purpose of this study is to summarize the current understanding of referred pain, including its pathogenesis, characteristics, diagnosis, and treatment. Recent findings Referred pain arises not only from pathologies primarily involving local tissue but also from lesions in distant structures. Central sensitization of convergent neurons and peripheral reflexes of dichotomizing afferent fibers are two theories proposed to explain the pathological mechanism of referred pain. Because syndromes related to referred pain of different origins overlap each other, it is challenging to define referred pain and identify its originating lesions. Although various approaches have been used in the diagnosis and treatment of referred pain, including conservative treatment, blockade, radiofrequency, and surgery, management of referred pain remains a clinical challenge. Summary Unlike radicular pain and neuropathic pain, referred pain is a less studied area, despite being common in clinics. Referred pain can derive from various spinal structures, and blockage helps identify the primary pathology. Due to the heterogeneity of referred pain, treatment outcomes remain uncertain. Further studies are needed to improve our understanding of referred pain.
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Öztürk İ, Fidanci H, Arlier Z. Neuropathic pain in peroneal nerve entrapment at the fibular head. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:1134-1140. [PMID: 36577412 PMCID: PMC9797269 DOI: 10.1055/s-0042-1758644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Peroneal neuropathy at the fibular head (PNFH) is a mononeuropathy that typically presents with drop foot and sensory abnormalities over the skin area innervated by the peroneal nerve. OBJECTIVE The aim of the present study was to evaluate neuropathic pain in patients with PNFH. METHODS Patients with clinical and electrodiagnostic features consistent with PNFH associated with weight loss, leg postures, or prolonged sleep were included in the present retrospective cohort study. Nerve conduction studies were performed in the bilateral lower extremities of all patients. The Leeds assessment of neuropathic symptoms and signs scale (LANSS) was applied to all patients. RESULTS Thirty-two PNFH patients (78% males) were included in the study. The LANSS score in the majority of patients was lower than 12. There was 1 patient with a LANSS score of 12. The electrodiagnostic features of 16 patients were compatible with axonal degeneration. The mean LANSS scores of PNFH patients with and without axonal degeneration were 4.3 ± 3.7 and 5.2 ± 2.9, respectively (p = 0.255). CONCLUSION The present study showed that neuropathic pain is a rare symptom in patients with PNFH associated with weight loss, leg postures, or prolonged sleep.
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Affiliation(s)
- İlker Öztürk
- Adana City Training and Research Hospital, Department of Neurology, Adana, Turkey.
| | - Halit Fidanci
- Adana City Training and Research Hospital, Department of Neurology, Division of Clinical Neurophysiology, Adana, Turkey.,Address for correspondence Halit Fidancı
| | - Zülfikar Arlier
- Adana City Training and Research Hospital, Department of Neurology, Adana, Turkey.
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Sun K, Jiang J, Wang Y, Sun X, Zhu J, Xu X, Sun J, Shi J. The role of nerve fibers and their neurotransmitters in regulating intervertebral disc degeneration. Ageing Res Rev 2022; 81:101733. [PMID: 36113765 DOI: 10.1016/j.arr.2022.101733] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/11/2022] [Accepted: 09/11/2022] [Indexed: 01/31/2023]
Abstract
Intervertebral disc degeneration (IVDD) has been the major contributor to chronic lower back pain (LBP). Abnormal apoptosis, senescence, and pyroptosis of IVD cells, extracellular matrix (ECM) degradation, and infiltration of immune cells are the major molecular alternations during IVDD. Changes at tissue level frequently occur at advanced IVD tissue. Ectopic ingrowth of nerves within inner annulus fibrosus (AF) and nucleus pulposus (NP) tissue has been considered as the primary cause for LBP. Innervation at IVD tissue mainly included sensory and sympathetic nerves, and many markers for these two types of nerves have been detected since 1940. In fact, in osteoarthritis (OA), beyond pain transmission, the direct regulation of neuropeptides on functions of chondrocytes have attracted researchers' great attention recently. Many physical and pathological similarities between joint and IVD have shed us the light on the neurogenic mechanism involved in IVDD. Here, an overview of the advances in the nervous system within IVD tissue will be performed, with a discussion on in the role of nerve fibers and their neurotransmitters in regulating IVDD. We hope this review can attract more research interest to address neuromodulation and IVDD itself, which will enhance our understanding of the contribution of neuromodulation to the structural changes within IVD tissue and inflammatory responses and will help identify novel therapeutic targets and enable the effective treatment of IVDD disease.
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Affiliation(s)
- Kaiqiang Sun
- Department of Orthopedic Surgery, Changzheng Hospital, Navy Medical University, No.415 Fengyang Road, Shanghai 200003, China; Department of Orthopedics, Naval Medical Center of PLA, China
| | - Jialin Jiang
- Department of Orthopedic Surgery, Changzheng Hospital, Navy Medical University, No.415 Fengyang Road, Shanghai 200003, China
| | - Yuan Wang
- Department of Orthopedic Surgery, Changzheng Hospital, Navy Medical University, No.415 Fengyang Road, Shanghai 200003, China
| | - Xiaofei Sun
- Department of Orthopedic Surgery, Changzheng Hospital, Navy Medical University, No.415 Fengyang Road, Shanghai 200003, China
| | - Jian Zhu
- Department of Orthopedic Surgery, Changzheng Hospital, Navy Medical University, No.415 Fengyang Road, Shanghai 200003, China
| | - Ximing Xu
- Department of Orthopedic Surgery, Changzheng Hospital, Navy Medical University, No.415 Fengyang Road, Shanghai 200003, China
| | - Jingchuan Sun
- Department of Orthopedic Surgery, Changzheng Hospital, Navy Medical University, No.415 Fengyang Road, Shanghai 200003, China.
| | - Jiangang Shi
- Department of Orthopedic Surgery, Changzheng Hospital, Navy Medical University, No.415 Fengyang Road, Shanghai 200003, China.
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Ex vivo biomechanical evaluation of Acute lumbar endplate injury and comparison to annulus fibrosus injury in a rat model. J Mech Behav Biomed Mater 2022; 131:105234. [DOI: 10.1016/j.jmbbm.2022.105234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/14/2022] [Accepted: 04/09/2022] [Indexed: 11/20/2022]
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Huang Y, Zhu L, Zhang W, Tang Q, Zhong Y. IL-10 alleviates radicular pain by inhibiting TNF-α/p65 dependent Nav1.7 up-regulation in DRG neurons of rats. Brain Res 2022; 1791:147997. [PMID: 35779581 DOI: 10.1016/j.brainres.2022.147997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/21/2022] [Accepted: 06/26/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Lumbar disc herniation (LDH) may induce radicular pain, the upregulation of voltage-gated sodium channels (VGSCs) in dorsal root ganglion (DRG) contributes to radicular pain by generating ectopic discharge of neurons, but the mechanism is unclear. Previously, we reported pro-inflammatory cytokine tumor necrosis factor-α (TNF-α) up-regulated VGSCs in diabetic neuropathy. In this study, we explored the effect of anti-inflammatory cytokine interleukin-10 (IL-10) on radicular pain and the possible mechanisms. METHODS Rat model of LDH was induced by implanting autologous nucleus pulposus (NP). Mechanical and thermal pain thresholds were assessed by von Frey filaments and hotplate test respectively. IL-10 and TNF-α level in DRG and cerebrospinal fluid (CSF) were assessed by Enzyme-linked immunosorbent assay (ELISA). IL-10 was intrathecally delivered for 12 days. The expression of IL-10R1 and sodium channel Nav1.7 was displayed by immunofluorescence staining. The protein level of TNF-α and p-p65 was measured by western blotting. RESULTS NP implantation increased Nav1.7 expression in DRG neurons, decreased IL-10 level and increased TNF-α level in DRG and CSF. IL-10 significantly alleviated pain behaviors of rats with NP. IL-10R1 was co-localized with neurons but not with satellite cells in DRG. IL-10 decreased Nav1.7 and TNF-α/p-p65 expression in DRG of rats with NP. Co-administration of TNF-α with IL-10 counteracted the effect of IL-10 on pain behaviors, Nav1.7 and TNF-α/p-p65 expression of rats with NP. CONCLUSIONS The study revealed that IL-10 alleviated radicular pain by inhibiting TNF-α/p-p65 dependent Nav1.7 up-regulation in DRG neurons.
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Affiliation(s)
- Yangliang Huang
- Department of Spine Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, China
| | - Lirong Zhu
- Key Laboratory of Neuroscience, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou 511436, China; Institute of Neuroscience and Department of Neurology of the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
| | - Weili Zhang
- Key Laboratory of Neuroscience, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou 511436, China; Institute of Neuroscience and Department of Neurology of the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
| | - Qian Tang
- Key Laboratory of Neuroscience, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou 511436, China; Institute of Neuroscience and Department of Neurology of the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China
| | - Yi Zhong
- Key Laboratory of Neuroscience, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou 511436, China; Institute of Neuroscience and Department of Neurology of the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou 510260, China.
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IL-1β promotes disc degeneration and inflammation through direct injection of intervertebral disc in a rat lumbar disc herniation model. Spine J 2021; 21:1031-1041. [PMID: 33460811 DOI: 10.1016/j.spinee.2021.01.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/04/2021] [Accepted: 01/12/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND CONTEXT Lumbar intervertebral disc herniation (LDH) is a common disease that causes low back pain, radiating leg pain, and sensory impairment. Preclinical studies rely heavily upon standardized animal models of human diseases to predict clinical treatment efficacy and to identify and investigate potential adverse events in human subjects. The current method for making the LDH model involves harvesting the nucleus pulposus (NP) from autologous coccygeal discs and applying to the lumbar nerve roots just proximal to the corresponding dorsal root ganglion. However, this surgical method generates a model that exhibits very different characteristics of disc herniation than that observed in human. PURPOSE To produce a rat LDH model that better resembles disc herniation in humans and a standardized and uniform LDH model using Interleukin-1 beta (IL-1β). STUDY DESIGN Experimental rat LDH model. METHODS We exposed the L5-6 disc dorsolaterally on the right side through hemi-laminectomy without nerve compression. Herniation was initiated by puncturing the exposed disc with a 30-gauge needle at a depth of 4 mm. Interleukin-1 beta (IL-1β) was injected simultaneously to heighten the pathological processes of disc degeneration, including inflammatory responses, matrix destruction, and herniation of the NP. We performed histological staining to assess morphological changes, immunohistochemistry to analyze inflammation- and pain-related expression within and around the puncture site of the L5-6 disc, and real-time polymerase chain reaction to examine expression of markers for degenerative processes. In addition, we performed locomotor tests on the rats. RESULTS We found that the IL-1β groups showed that the border between the annulus fibrosis and nucleus pulposus was severely interrupted compared to that of the control (puncture only) group. And, the injection of IL-1β leads to accelerated disc degeneration and inflammation in a more consistent manner in LDH model. Functional deficit was consistently induced by puncturing and injection of IL-1β in the exposed disc. CONCLUSIONS The method proposed here can be used as an index to control the severity of disc degeneration and inflammation through the injected IL-1β concentration concurrent with surgically induced herniation. CLINICAL SIGNIFICANCE Our proposed model may facilitate research in drug development to evaluate the efficacy of potential therapeutic agents for disc herniation and neuropathic pain and may also be used for nonclinical studies to more accurately assess the effectiveness of various treatment strategies according to the severity of disc degeneration.
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Fidancı H, Öztürk İ. The relationship between nerve conduction studies and neuropathic pain in sciatic nerve injury due to intramuscular injection. Korean J Pain 2021; 34:124-131. [PMID: 33380575 PMCID: PMC7783856 DOI: 10.3344/kjp.2021.34.1.124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/28/2020] [Accepted: 12/09/2020] [Indexed: 02/03/2023] Open
Abstract
Background Sciatic nerve injury due to intramuscular injection (SNIII) is still a health problem. This study aimed to determine whether there is a correlation between neuropathic pain and electrodiagnostic findings in SNIII. Methods Patients whose clinical and electrodiagnostic findings were compatible with SNIII participated in this retrospective cohort study. Compound muscle action potential (CMAP) and sensory nerve action potential (SNAP) amplitudes of the sural, superficial peroneal, peroneal, and tibial nerves were graded from 1 to 4. Leeds assessment of neuropathic symptoms and signs scale (LANSS) was applied to all patients. Results Forty-eight patients were included in the study, 67% of whom had a LANSS score ≥ 12. Sural SNAP amplitude abnormalities were present in 8 (50%) out of 16 patients with a LANSS score < 12, and 28 (87.5%) out of 32 patients with a LANSS score ≥ 12, with significant differences between the groups (P = 0.011). There was a positive correlation between the LANSS score and the sural SNAP amplitude grading (P = 0.001, r = 0.476). A similar positive correlation was also found in the LANSS score and the tibial nerve CMAP amplitude grading (P = 0.004, r = 0.410). Conclusions This study showed a positive correlation between the severity of tibial nerve CMAP/sural SNAP amplitude abnormality and LANSS score in SNIII. Neuropathic pain may be more common in SNIII patients with sural nerve SNAP amplitude abnormality.
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Affiliation(s)
- Halit Fidancı
- Department of Neurology, Division of Clinical Neurophysiology, Adana City Training and Research Hospital, Adana, Turkey.,Department of Neurology, Adana City Training and Research Hospital, Adana, Turkey
| | - İlker Öztürk
- Department of Neurology, Adana City Training and Research Hospital, Adana, Turkey
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Zhang S, Hu B, Liu W, Wang P, Lv X, Chen S, Shao Z. The role of structure and function changes of sensory nervous system in intervertebral disc-related low back pain. Osteoarthritis Cartilage 2021; 29:17-27. [PMID: 33007412 DOI: 10.1016/j.joca.2020.09.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/18/2020] [Accepted: 09/21/2020] [Indexed: 02/06/2023]
Abstract
Low back pain (LBP) is a common musculoskeletal symptom, which can be developed in multiple clinical diseases. It is widely recognized that intervertebral disc (IVD) degeneration (IVDD) is one of the leading causes of LBP. However, the pathogenesis of IVD-related LBP is still controversial, and the treatment means are also insufficient to date. In recent decades, the role of structure and function changes of sensory nervous system in the induction and the maintenance of LBP is drawing more and more attention. With the progress of IVDD, IVD cell exhaustion and extracellular matrix degradation result in IVD structural damage, while neovascularization, innervation and inflammatory activation further deteriorate the microenvironment of IVD. New nerve ingrowth into degenerated IVD amplifies the impacts of IVD-derived nociceptive molecules on sensory endings. Moreover, IVDD is usually accompanied with disc herniation, which could injure and inflame affected nerves. Under mechanical and pro-inflammatory stimulation, the pain-transmitting pathway exhibits a sensitized function state and ultimately leads to LBP. Hence, relevant pathogenic factors, such as neurotrophins, ion channels, inflammatory factors, etc., are supposed to serve as promising therapeutic targets for LBP. The purpose of this review is to comprehensively summarize the current evidence on 1) the pathological changes of sensory nervous system during IVDD and their association with LBP, and 2) potential therapeutic strategies for LBP targeting relevant pathogenic factors.
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Affiliation(s)
- S Zhang
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
| | - B Hu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
| | - W Liu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
| | - P Wang
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
| | - X Lv
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
| | - S Chen
- Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China.
| | - Z Shao
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
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SFKs/p38 Pathway is Involved in Radicular Pain by Promoting Spinal Expression of Pro-Inflammatory Cytokines in a Rat Model of Lumbar Disc Herniation. Spine (Phila Pa 1976) 2019; 44:E1112-E1121. [PMID: 31261268 DOI: 10.1097/brs.0000000000003076] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A controlled, randomized, animal study. OBJECTIVE The aim of this study was to investigate the role of src-family kinases/p38 pathway in a rat model of lumbar disc herniation (LDH). SUMMARY OF BACKGROUND DATA LDH always generates radicular pain, and the mechanism remains unclear. We have reported that spinal src-family kinases (SFKs) may be involved in the process, but the downstream mechanism needs further investigation. METHODS LDH was induced by implantation of autologous nucleus pulposus (NP), harvest from the tail, in lumbar 4/5 spinal nerve roots of rat. Von Frey filaments and radiant heat tests were performed to determine mechanical and thermal pain threshold respectively. Basso, Beattie, and Bresnahan (BBB) scale was assessed to test the locomotor function. The protein level of p-SFKs, t-SFKs, p-p38, t-p38 in spinal cord was examined by western blotting analysis. Cellular location of p-p38 was determined by immunochemistry staining. Spinal tumor necrosis factor-alpha (TNF-α), interleukin (IL)-1β, and IL-6 levels were detected by enzyme-linked immunosorbent assay (ELISA). RESULTS Rats with NP implantation showed persistent ipsilateral mechanical allodynia and thermal hyperalgesia, which manifested as obvious decrease of paw withdrawal threshold (PWT) and paw withdrawal latency (PWL). BBB scale indicated the locomotor function of hindpaws in rats with NP implantation kept intact. Western blotting and immunohistochemistry staining revealed that phosphorylated SFKs (p-SFKs) and phosphorylated p38 MAPK (p-p38) were sequentially upregulated in ipsilateral spinal dorsal horn, but not in contralateral side of rats with NP. Intrathecal delivery of SFKs inhibitor reduced spinal p-p38 expression. Both SFKs and p38 inhibitors alleviated pain behaviors in a dose-responsive manner without disturbing locomotor function and reduced spinal expression of TNF-α, IL-1β, and IL-6 in rats with NP. CONCLUSION Spinal SFKs contribute to radicular pain by activation of p38 MAPK and increasing pro-inflammatory cytokines expression in rats with NP implantation. Targeting SFKs/p38 pathway may be helpful for alleviating radicular pain. LEVEL OF EVIDENCE N/A.
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Schwertner-Tiepelmann N, Hagedorn-Wiesner A, Erschig C, Beilecke K, Schwab F, Tunn R. Clinical relevance of neurological evaluation in patients suffering urinary retention in the absence of subvesical obstruction. Arch Gynecol Obstet 2017; 296:1017-1025. [PMID: 28900705 DOI: 10.1007/s00404-017-4519-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/04/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Clinical relevance of neurological evaluation in patients suffered urinary retention in the absence of subvesical obstruction. Determining whether (1) women complaining residual bladder volume without prolapse and obstruction always suffer pudendal nerve damage; (2) neurogenic damage can be linked to patients history/clinical examination; (3) therapy alters regarding to neurological findings; and (4) electromyography (EMG) of musculus sphincter ani externus (MSAE) can be omitted with electronically stimulated pudendal nerve latency (ESPL) as the standard investigation. METHODS Women with urinary retention without ≥stage 2 prolapse or obstruction have neurological investigation including vaginally and anally pudendal terminal nerve latency (PTNL) (>2.4 ms considered abnormal) and EMG seen 7/2005-04/2010. RESULTS (1) 148/180 (82.2%) suffered at least moderate neurogenic damage and (2) severe neurogenic damage occurs with urge odds ratio (OR) = 3.1 or age (OR = 3.2). Correlations: spasticity with therapy changes (OR = 11.1), latencies. (a) Anally: (i) right and peripheral neuropathy (PNP) (OR = 2.5), chemotherapy (OR = 5.0); (ii) left and PNP (OR = 3.9), chemotherapy (OR = 4.8); (iii) left or right with PNP (OR = 3.9), chemotherapy (OR = 6.8); and (iv) left and right with chemotherapy (OR = 5.0). (b) Vaginally: (i) right with age >60 (OR = 3.2), radical operation (OR = 10.6); (ii) left with diabetes mellitus (OR = 2.5); and (iii) left or right with age (OR = 3.3), radical operation (OR = 8.7). (3) 19.6% therapy changes (36 patients). (4) Neither EMG nor ESPL can be replaced one by another (p = 0.12 anal, p = 0.05 vaginal). CONCLUSION Red flags are neurogenic damage, age >60, chemotherapy, PNP, radical operation or diabetes. In unclear situations, EMG and ESPL need to be performed to gain relevant information.
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Affiliation(s)
- N Schwertner-Tiepelmann
- Department of Urogynecology, German Pelvic Floor Center, St. Hedwig Hospital, Große Hamburger Straße 5-11, 10115, Berlin, Germany.
| | | | - C Erschig
- Department of Surgery, Auguste-Victoria-Hospital, Berlin, Germany
| | - K Beilecke
- Department of Urogynecology, German Pelvic Floor Center, St. Hedwig Hospital, Große Hamburger Straße 5-11, 10115, Berlin, Germany
| | - F Schwab
- Institute of Hygiene and Environmental Medicine, Charité, Berlin, Germany
| | - R Tunn
- Department of Urogynecology, German Pelvic Floor Center, St. Hedwig Hospital, Große Hamburger Straße 5-11, 10115, Berlin, Germany
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Jin L, Ding M, Oklopcic A, Aghdasi B, Xiao L, Li Z, Jevtovic-Todorovic V, Li X. Nanoparticle fullerol alleviates radiculopathy via NLRP3 inflammasome and neuropeptides. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2017; 13:2049-2059. [PMID: 28404518 DOI: 10.1016/j.nano.2017.03.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 02/13/2017] [Accepted: 03/25/2017] [Indexed: 01/26/2023]
Abstract
The present study aimed to evaluate the analgesic effect of the antioxidant nanoparticle fullerol in a mouse radiculopathy and a dorsal root ganglion (DRG) culture models. Intervertebral disk degeneration causes significant hyperalgesia and nerve inflammation. Pain sensitization and inflammatory reaction were counteracted by fullerol when disk material was bathed in 10 or 100μM of fullerol prior to implantation. Immunohistochemistry showed similar massive IBA1 positive macrophage infiltration surrounding implanted disk material among groups, but IL-1β and IL-6 expression was decreased in the fullerol treated group. In the DRG explant culture, after treatment with TNF-α, the expression of IL-1β, NLRP3, and caspase 1 was significantly increased but this was reversed by the addition of fullerol. In addition, fullerol also decreased the expression of substance P and CGRP in the cultured DRGs. Nanoparticle fullerol effectively counteracts pain sensitization and the inflammatory cascade caused by disk degeneration.
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Affiliation(s)
- Li Jin
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Mengmeng Ding
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Azra Oklopcic
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Bayan Aghdasi
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Li Xiao
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Ziyi Li
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Vesna Jevtovic-Todorovic
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA; Department of Anesthesiology, University of Colorado, Aurora, CO, USA.
| | - Xudong Li
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA.
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Lai A, Moon A, Purmessur D, Skovrlj B, Laudier DM, Winkelstein BA, Cho SK, Hecht AC, Iatridis JC. Annular puncture with tumor necrosis factor-alpha injection enhances painful behavior with disc degeneration in vivo. Spine J 2016; 16:420-31. [PMID: 26610672 PMCID: PMC4913353 DOI: 10.1016/j.spinee.2015.11.019] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 10/01/2015] [Accepted: 11/10/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Painfulintervertebral disc degeneration is extremely common and costly. Effective treatments are lacking because the nature of discogenic pain is complex with limited capacity to distinguish painful conditions from age-related changes in the spine. Hypothesized sources of discogenic pain include chronic inflammation, neurovascular ingrowth, and structural disruption. PURPOSE This study aimed to investigate inflammation, pro-neurovascular growth factors, and structural disruption as sources of painful disc degeneration STUDY DESIGN/SETTING This study used an in vivo study to address these hypothesized mechanisms with anterior intradiscal injections of tumor necrosis factor-alpha (TNFα), pro-neurovascular growth factors: nerve growth factor and vascular endothelial growth factor (NGF and VEGF), and saline with additional sham surgery and naïve controls. Depth of annular puncture was also evaluated for its effects on structural and painful degeneration. METHODS Rat lumbar discs were punctured (shallow or deeper puncture) and intradiscally injected with saline, TNFα, or NGF and VEGF. Structural disc degeneration was assessed using X-ray, magnetic resonance imaging (MRI), and histology. The rat painful condition was evaluated using Von Frey hyperalgesia measurements, and substance P immunostaining in dorsal root ganglion (DRG) was performed to determine the source of pain. RESULTS Saline injection increased painful responses with degenerative changes in disc height, MRI intensity, and morphologies of disc structure and cell. TNFα and NGF/VEGF accelerated painful behavior, and TNFα-injected animals had increased substance P in DRGs. Deeper punctures led to more severe disc degeneration. Multiple regression analysis showed that the painful behavior was correlated with disc height loss. CONCLUSIONS We concluded that rate and severity of structural disc degeneration was associated with the amount of annular disruption and puncture depth. The painful behavior was associated with disc height loss and discal inflammatory state, whereas pro-inflammatory cytokines might play a more important role in the level of pain, which might have resulted from enhanced DRG sensitization. These in vivo painful disc degeneration models with different severities of structural changes may be useful for investigating discogenic pain mechanisms and for screening therapies, although interpretations must note the differences between all surgically induced animal models and the human condition.
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Affiliation(s)
- Alon Lai
- Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, Box 1188, Orthopaedics, New York, NY 10029-6574
| | - Andrew Moon
- Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, Box 1188, Orthopaedics, New York, NY 10029-6574
| | - Devina Purmessur
- Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, Box 1188, Orthopaedics, New York, NY 10029-6574,The Ohio State University, Dorothy Davis Heart and Lung Research Institute, 473 W 12th Avenue, Room 012L, Columbus OH 43210
| | | | - Damien M. Laudier
- Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, Box 1188, Orthopaedics, New York, NY 10029-6574
| | | | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, Box 1188, Orthopaedics, New York, NY 10029-6574
| | - Andrew C. Hecht
- Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, Box 1188, Orthopaedics, New York, NY 10029-6574
| | - James C. Iatridis
- Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, Box 1188, Orthopaedics, New York, NY 10029-6574,Corresponding author. Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, Box 1188, Orthopaedics, New York, NY 10029-6574, USA. Tel.: 212 241 1517; fax: 212 876 3168. (J.C. Iatridis)
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Cho HK, Kim SY, Choi MJ, Baek SO, Kwak SG, Ahn SH. The Effect of GCSB-5 a New Herbal Medicine on Changes in Pain Behavior and Neuroglial Activation in a Rat Model of Lumbar Disc Herniation. J Korean Neurosurg Soc 2016; 59:98-105. [PMID: 26962414 PMCID: PMC4783491 DOI: 10.3340/jkns.2016.59.2.98] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 09/24/2015] [Accepted: 02/10/2016] [Indexed: 01/02/2023] Open
Abstract
Objective Lumbar disc herniation can induce sciatica by mechanical compression and/or chemical irritation. The aim of this study was to compare the effects of GCSB-5 (Shinbaro®) and NSAIDs on pain-related behavior and on the expressions of microglia, astrocytes, CGRP, TRPV1, IL-6, and CX3CL1 in a rat model of lumbar disc herniation. Methods 112 male Sprague-Dawley rats underwent implantation of nucleus pulposus to a dorsal root ganglion (DRG). Rats were divided into five groups as follows; a saline group (the vehicle control group) (n=27), a 10 mg/kg aceclofenac group (the aceclofenac group) (n=22), and 100, 300 or 600 mg/kg GCSB-5 groups (the GCSB-5 100, 300, or 600 groups) (n=21 for each group). Rats were tested for mechanical allodynia at 3 days after surgery and at 1 day, 3 days, 7 days, 14 days, 21 days, 28 days, 35 days, 42 days, 49 days, and 56 days after treatment commencement. Immunohistochemical staining of microglia (Iba1), astrocytes (GFAP), CGRP, and TRPV1, and PCR for IL-6 and CX3CL1 were performed on spinal dorsal horns and DRGs at 56 days after medication commencement. Results After 56 days of GCSB-5 300 administration, mechanical withdrawal thresholds were significantly increased (p<0.05), and immunohisto-chemical expressions of Iba1, GFAP, CGRP, and TRPV1 were reduced than other groups, but this difference was not statistically significant. Conclusion These results indicate GCSB-5 reduces mechanical allodynia and downregulates neuroglial activity and the expressions of CGRP and TRPV1 in the spinal segments of a rat model of lumbar disc herniation.
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Affiliation(s)
- Hee Kyung Cho
- Department of Physical Medicine and Rehabilitation, College of Medicine, Catholic University of Daegu, Daegu, Korea
| | - So-Yeon Kim
- Medical Devices Clinical Trial Center, College of Medicine, Yeungnam University, Daegu, Korea
| | - Mi Jung Choi
- Medical Devices Clinical Trial Center, College of Medicine, Yeungnam University, Daegu, Korea
| | - Seung Ok Baek
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, Korea
| | - Sang Gyu Kwak
- Department of Medical Statistics, College of Medicine, Catholic University of Daegu, Daegu, Korea
| | - Sang Ho Ahn
- Medical Devices Clinical Trial Center, College of Medicine, Yeungnam University, Daegu, Korea.; Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, Korea
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Zhang Y, Liu L, Wang S, Zhao Y, Liu Y, Li J, Nie L, Cheng L. Production of CCL20 on nucleus pulposus cells recruits IL-17-producing cells to degenerated IVD tissues in rat models. J Mol Histol 2015; 47:81-9. [DOI: 10.1007/s10735-015-9651-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 12/20/2015] [Indexed: 12/27/2022]
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Cho HK, Ahn SH, Kim SY, Choi MJ, Hwang SJ, Cho YW. Changes in the Expressions of Iba1 and Calcitonin Gene-Related Peptide in Adjacent Lumbar Spinal Segments after Lumbar Disc Herniation in a Rat Model. J Korean Med Sci 2015; 30:1902-10. [PMID: 26713069 PMCID: PMC4689838 DOI: 10.3346/jkms.2015.30.12.1902] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 10/28/2015] [Indexed: 12/14/2022] Open
Abstract
Lumbar disc herniation is commonly encountered in clinical practice and can induce sciatica due to mechanical and/or chemical irritation and the release of proinflammatory cytokines. However, symptoms are not confined to the affected spinal cord segment. The purpose of this study was to determine whether multisegmental molecular changes exist between adjacent lumbar spinal segments using a rat model of lumbar disc herniation. Twenty-nine male Sprague-Dawley rats were randomly assigned to either a sham-operated group (n=10) or a nucleus pulposus (NP)-exposed group (n=19). Rats in the NP-exposed group were further subdivided into a significant pain subgroup (n=12) and a no significant pain subgroup (n=7) using mechanical pain thresholds determined von Frey filaments. Immunohistochemical stainings of microglia (ionized calcium-binding adapter molecule 1; Iba1), astrocytes (glial fibrillary acidic protein; GFAP), calcitonin gene-related peptide (CGRP), and transient receptor potential vanilloid 1 (TRPV1) was performed in spinal dorsal horns and dorsal root ganglions (DRGs) at 10 days after surgery. It was found immunoreactivity for Iba1-positive microglia was higher in the L5 (P=0.004) dorsal horn and in the ipsilateral L4 (P=0.009), L6 (P=0.002), and S1 (P=0.002) dorsal horns in the NP-exposed group than in the sham-operated group. The expression of CGRP was also significantly higher in ipsilateral L3, L4, L6, and S1 segments and in L5 DRGs at 10 days after surgery in the NP-exposed group than in the sham-operated group (P<0.001). Our results indicate that lumbar disc herniation upregulates microglial activity and CGRP expression in many adjacent and ipsilateral lumbar spinal segments.
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Affiliation(s)
- Hee Kyung Cho
- Department of Physical Medicine and Rehabilitation, College of Medicine, Daegu Catholic University, Daegu, Korea
| | - Sang Ho Ahn
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, Korea
- Medical Devices Clinical Trial Center, Yeungnam University, Daegu, Korea
| | - So-Yeon Kim
- Medical Devices Clinical Trial Center, Yeungnam University, Daegu, Korea
| | - Mi-Jung Choi
- Medical Devices Clinical Trial Center, Yeungnam University, Daegu, Korea
| | - Se Jin Hwang
- Department of Anatomy and Cell Biology, School of Medicine, Hanyang University, Seoul, Korea
| | - Yun Woo Cho
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, Korea
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Ma D, Liang Y, Wang D, Liu Z, Zhang W, Ma T, Zhang L, Lu X, Cai Z. Trend of the incidence of lumbar disc herniation: decreasing with aging in the elderly. Clin Interv Aging 2013; 8:1047-50. [PMID: 23966775 PMCID: PMC3743527 DOI: 10.2147/cia.s49698] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Compelling evidence has shown that the incidence of lumbar disc herniation (LDH) increases with age. In this study, retrospective clinical analysis of 601 cases of LDH has been conducted to investigate the role of age in the incidence of LDH in the elderly. The aim of the study is to investigate the relationship between the process of aging and the occurrence of LDH in old adults. METHODS Clinical cases (n = 601) of LDH were retrospectively analyzed. RESULTS The imaging examination with computed tomography and/or magnetic resonance imaging showed the occurrence of degeneration in LDH patients over 65 years of age. The most common site of LDH is toward the bottom of the spine at L4-L5 and/or L5-S1. The incidence of LDH drops with age in the elderly, especially after the age of 80 years. There is an obvious decrease in LDH in the elderly female. CONCLUSION A decreasing incidence of LDH with aging occurs in the elderly. This investigation indicates that aging is not a contributor to the performance of LDH in the elderly although the incidence of LDH is proportional to age.
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Affiliation(s)
- Daoyou Ma
- Department of Rehabilitation, the Lu'an Affiliated Hospital of Anhui Medical University, Lu'an People's Hospital, Lu'an, Anhui Province, People's Republic of China
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Cho HK, Cho YW, Kim EH, Sluijter ME, Hwang SJ, Ahn SH. Changes in pain behavior and glial activation in the spinal dorsal horn after pulsed radiofrequency current administration to the dorsal root ganglion in a rat model of lumbar disc herniation: laboratory investigation. J Neurosurg Spine 2013; 19:256-63. [PMID: 23746090 DOI: 10.3171/2013.5.spine12731] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECT Herniated discs can induce sciatica by mechanical compression and/or chemical irritation caused by proinflammatory cytokines. Using immunohistochemistry methods in the dorsal horn of a rat model of lumbar disc herniation, the authors investigated the effects of pulsed radiofrequency (PRF) current administration to the dorsal root ganglion (DRG) on pain-related behavior and activation of microglia, astrocytes, and mitogen-activated protein kinase. METHODS A total of 33 Sprague-Dawley rats were randomly assigned to either a sham-operated group (n = 10) or a nucleus pulposus (NP)-exposed group (n = 23). Rats in the NP-exposed group were further subdivided into NP exposed with sham stimulation (NP+sham stimulation, n = 10), NP exposed with PRF (NP+PRF, n = 10), or euthanasia 10 days after NP exposure (n = 3). The DRGs in the NP+PRF rats were exposed to PRF waves (2 Hz) for 120 seconds at 45 V on postoperative Day 10. Rats were tested for mechanical allodynia 10 days after surgery and at 8 hours, 1 day, 3 days, 10 days, 20 days, and 40 days after PRF administration. Immunohistochemical staining of astrocytes (glial fibrillary acidic protein), microglia (OX-42), and phosphorylated extracellular signal-regulated kinases (pERKs) in the spinal dorsal horn was performed at 41 days after PRF administration. RESULTS Starting at 8 hours after PRF administration, mechanical withdrawal thresholds dramatically increased; this response persisted for 40 days (p < 0.05). After PRF administration, immunohistochemical expressions of OX-42 and pERK in the spinal dorsal horn were quantitatively reduced (p < 0.05). CONCLUSIONS Pulsed radiofrequency administration to the DRG reduced mechanical allodynia and downregulated microglia activity and pERK expression in the spinal dorsal horn of a rat model of lumbar disc herniation.
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Affiliation(s)
- Hee Kyung Cho
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, Republic of Korea
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Forero JJ, Ortiz-Corredor F, Díaz-Ruiz J, Lozano-Castillo A, Mendoza-Pulido C. Changes in electromyographic results of patients with lumbar radiculopathy: a follow-up study. Arch Phys Med Rehabil 2013; 94:1287-92. [PMID: 23313354 DOI: 10.1016/j.apmr.2012.12.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Revised: 12/24/2012] [Accepted: 12/26/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the neurophysiologic changes in a group of patients with lumbar radiculopathy 5 to 12 months after their first electromyographic examination. DESIGN A prospective group of patients with a case definition of lumbar radiculopathy was reassessed between 5 and 12 months after their first clinical, functional, imaging, and neurophysiologic evaluation. Both the lumbar paraspinals (in which the mini-mapping technique was used) and the same lower limb muscles were explored in every patient. Relevant abnormalities were (1) positive sharp waves/fibrillation potentials, (2) polyphasic motor unit potentials, and (3) large-amplitude/long-duration motor unit potentials. Patients were sorted into 5 groups based on the type and distribution of neurophysiologic abnormalities: from 0 (no abnormalities) to 4 (denervation signs in 2 lower limb muscles and paraspinals). Patients' subjective perception of any improvement or worsening of their condition was also recorded. SETTING A referral center for neurophysiologic evaluation. PARTICIPANTS A consecutive sample of patients (N=91) with a clinical definition of lumbar radiculopathy (lumbar pain radiating down the leg and below the knee) referred for neurophysiologic assessment was selected for an initial clinical, functional, and neurophysiologic evaluation. Patients were called for a second evaluation (between 5 and 12mo). Thirty-eight (42% of the initial sample) were willing/eligible for the second evaluation. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Changes in (1) electromyographic results; (2) patients' subjective perception of pain; and (3) quality of life, based on the Roland-Morris Questionnaire and Medical Outcomes Study 36-Item Short-Form Health Survey scores. RESULTS Paraspinal muscles were most frequently affected. Neurophysiologic abnormalities had improved on reassessment. Clinical improvement was more significant for those patients with initially abnormal electromyographic results. CONCLUSIONS There was clinical as well as electromyographic improvement in patients with lumbar radiculopathy within the first year of the initial diagnosis.
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Affiliation(s)
- John Jairo Forero
- Centro de Investigación en Fisiatría y Electrodiagnóstico, Bogotá, Colombia
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Abstract
The evaluation of patients with suspected lumbar radiculopathy is one of the most common reasons patients are referred for electrodiagnostic testing. The utility of this study depends on the expertise of the physician who plans, performs, and completes the study. This article reviews the strengths and weaknesses of electrodiagnosis to make this diagnosis, as well as the clinical reasoning of appropriate study planning. The current use of electrodiagnostic testing to determine prognosis and treatment outcomes is also discussed.
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Affiliation(s)
- Karen Barr
- Rehabilitation Medicine, University of Washington, Seattle, WA 98195-6490, USA.
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Bibliography Current World Literature. CURRENT ORTHOPAEDIC PRACTICE 2012. [DOI: 10.1097/bco.0b013e318256e7f2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Choi GS, Ahn SH, Cho YW, Lee DG. Long-term effect of pulsed radiofrequency on chronic cervical radicular pain refractory to repeated transforaminal epidural steroid injections. PAIN MEDICINE 2012; 13:368-75. [PMID: 22296730 DOI: 10.1111/j.1526-4637.2011.01313.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The article aims to evaluate the long-term effectiveness and safety of pulsed radiofrequency (PRF) on the dorsal root ganglion (DRG) in patients with chronic cervical radicular pain refractory to repeated transforaminal epidural steroid injections (TFESIs). DESIGN This is a prospective observational study. METHODS We retrospectively reviewed data on 112 subjects who had received repeated TFESIs for cervical radicular pain. Twenty-nine of those 112 patients continued to complain of persistent cervical radicular pain, despite an average of three repeated TFESIs. Among 29 patients with sustained arm pain of over 4 on the numerical rating scale (NRS), a total of 21 patients were included prospectively. Those 21 patients underwent PRF on the symptomatic cervical DRG and were evaluated carefully for neurologic deficits and side effects. The clinical outcomes were measured via NRS for arm pain before treatment, and 1, 3, 6, and 12 months after treatment. Successful pain relief was defined as a 50% or more reduction in the NRS score as compared with the pretreatment score. After 12 months, patients' satisfaction levels with treatment were determined. RESULTS Fourteen of the 21 patients (66.7%) after cervical PRF stimulation reported pain relief of 50% or more at the 3-month and 12-month follow-up periods, respectively. Fifteen of the 21 patients (71.4%) were satisfied with their outcome at 12 months' posttreatment. No serious adverse effects were observed. CONCLUSION Application of PRF to the DRG appears to be an effective and relatively safe intervention technique for chronic cervical radicular pain refractory to repeated TFESIs.
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Affiliation(s)
- Gyu-Sik Choi
- Department of Rehabilitation Medicine, College of Medicine, Yeungnam University, Nam-Gu, Daegu, Korea
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