Systematic Literature Review of Spinal Decompression Via Motorized Traction for Chronic Discogenic Low Back Pain

Effect of Nonsurgical Spinal Decompression on Intensity of Pain and Herniated Disc Volume in Subacute Lumbar Herniated Disc

OBJECTIVE

Nonsurgical spinal decompression therapy (NSDT) is a conservative treatment for the lumbosacral herniated intervertebral disc (L-HIVD). This study aimed to evaluate the clinical effectiveness of the NSDT and change in disc volume through magnetic resonance imaging (MRI) in subacute L-HIVD.

METHODS

Sixty patients with subacute L-HIVD were randomized into either the decompression group (group D, n = 30) or the nondecompression group (group N, n = 30). In group D, NSDT was performed ten times in eight weeks. In group N, pseudodecompression therapy (no force) was performed with the same protocol. Lower back and lower leg pain intensities and functional improvements were measured by the visual analog scale and the Korean Oswestry Disability Index (K-ODI). The change in the lumbosacral disc herniation index (HI) was evaluated through a follow-up MRI three months after the therapy.

RESULTS

The lower leg pain intensity in group D was lower than that in group N at two months (p=0.028). Additionally, there were significantly lower K-ODI scores in group D at two and three months (p=0.023, 0.019) than in group N. The change in HI after the therapy was -27.6 ± 27.5 (%) in group D and -7.1 ± 24.9 (%) in group N, with a significant difference (p=0.017). Approximately 26.9% of patients in group D and no patients in group N showed over 50% reduction in HI (p=0.031).

CONCLUSION

NSDT may be a suitable treatment option for conservative treatment of subacute L-HIVD.

Short-Term Effect of Lumbar Traction on Intervertebral Discs in Patients with Low Back Pain: Correlation between the T2 Value and ODI/VAS Score

OBJECTIVE

The effect of lumbar traction on low back pain (LBP) patients is controversial. Our study aims to assess changes in the intervertebral disc water content after lumbar traction using T2 mapping and explore the correlation between changes in the T2 value and Oswestry Disability Index (ODI)/visual analogue scale (VAS) score.

DESIGN

Lumbar spine magnetic resonance imaging was performed, and the ODI/VAS scores were recorded in all 48 patients. Midsagittal T2-weighted imaging and T2 mapping were performed to determine the Pfirrmann grade and T2 value. Then, the T2 values were compared between pre- and posttraction, and the correlation between changes in the T2 value and ODI/VAS scores were examined.

RESULTS

In the traction group, the changes in the nucleus pulposus (NP) T2 values for Pfirrmann grades II-IV and the annulus fibrosus (AF) T2 values for Pfirrmann grade II were statistically significant after traction (P < 0.05). Changes in the mean NP T2 value of 5 discs in each patient and in the ODI/VAS score showed a strong correlation (r = 0.822, r = 0.793).

CONCLUSION

T2 mapping can be used to evaluate changes in the intervertebral disc water content. Ten sessions of traction resulted in a significant increase in quantitative T2 measurements of the NP in discs for Pfirrmann grade II-IV degeneration and remission of the patients' clinical symptoms in the following 6 months. Changes in the mean NP T2 value of 5 discs in each patient were strongly correlated with changes in the ODI/VAS score.

Effects of Nonsurgical Spinal Decompression Treatment on the Level of Pain and Quality of Life in Patients with Cervical or Lumbar Disc Herniation: A Retrospective Observational Study

Background: This study aims to statistically analyze and compare the curative effect and satisfaction level between typical traditional Korean medicine treatment and nonsurgical spinal decompression treatment.Methods: Of the patients who were diagnosed with the cervical or lumbar herniated intervertebral disc at the Department of Acupuncture and Moxibustion Medicine at the Daejeon Korean Medicine Hospital from April 14^th to August 25^th, 2019, this study retrospectively analyzed the medical records of 31 patients who underwent nonsurgical spinal decompression treatment and traditional Korean medicine (assigned to Group A) and another 31 patients who received typical traditional Korean medicine alone (assigned to Group B). The clinical data were analyzed using IBM SPSS Version 23.0.Results: No statistically significant differences appeared in terms of sociodemographic, condition, and therapeutic characteristics, except whether the patient received Western medicine treatment, before or after a treatment with traditional Korean medicine. Group A exhibited higher variations in numeric rating scale, EuroQol- 5 dimension and EuroQol visual analogue scale scores compared to Group B as determined by independent sample <i>t</i> test and analysis of covariance. In addition, the satisfaction score of Group A was higher than that of Group B The result of cross analysis revealed that desire for continued treatment in Group A was higher than that of Group B.Conclusion: This retrospective observational study showed that the patients with nonsurgical spinal decompression treatment reported a greater reduction in pain, improved quality of life and satisfaction than patients receiving typical traditional Korean medicine.

Effect of spinal decompression therapy and core stabilization exercises in management of lumbar disc prolapse: A single blind randomized controlled trial

BACKGROUND

Spinal decompression therapy (SDT) has recently been used as a conservative treatment for lumbar disc prolapse (LDP). The effectiveness of SDT when compared with other conservative techniques with a well-designed randomized controlled trials is lacking.

OBJECTIVE

To find the efficacy of SDT and core stabilization exercises (CSE) on pain and functional disability in individuals with chronic LDP, and to compare with CSE alone.

METHODS

This single blind randomized controlled trial included thirty-one participants with a mean age of 38.68 ± 8.79 having chronic LDP with or without radiating symptoms were included in the study. The study group received SDT with CSE and control group received CSE alone along with interferential therapy for both groups. Pain and disability were estimated by Numerical Rating Scale (NRS) and Modified Oswestry Questionnaire (mOQ).

RESULTS

The results demonstrated significant within-group improvements in all outcomes in both groups, the mean differences between pre to post intervention in SDT with CSE group were (NRS: 4.75, t= 12.81, p⩽ 0.001) and (mOQ: 45.13, t= 29.34, p⩽ 0.001), while in CSE group (NRS: 2.60, t= 13.67, p⩽ 0.001) and (mOQ: 27.67, t= 24.52, p⩽ 0.001).

CONCLUSIONS

A combination of SDT with CSE has proven to be more significant when compared with CSE alone to reduce pain and disability in subjects with chronic LDP.

A multicentre randomized controlled follow-up study of the effects of the underwater traction therapy in chronic low back pain

Low back pain (LBP) is one of the most costly diseases in the developed world. This study aimed to investigate the effects of underwater traction therapy on chronic low back pain. The primary objective was to prove that underwater traction therapy has favorable effects on LBP. Our secondary objective was to evaluate whether it also leads to improvement in the quality of life. This is a prospective, multicenter, follow-up study. A total of 176 patients with more than 3 months of low back pain enrolled from outpatient clinics were randomized into three groups: underwater weight bath traction therapy and non-steroidal anti-inflammatory drugs (NSAIDs); weight bath; and only NSAIDs. The following parameters were measured before, right after, and 9 weeks after the 3-week therapy: levels of low back pain in rest and during activity were tested using the visual analogue scale (VAS), the Oswestry Low Back Disability Questionnaire, and the EuroQol-5D-5L Questionnaire.The VAS levels improved significantly (p < 0.05) in both underwater weight bath traction therapy groups by the end of the treatment, whereas the improvement in the third group was not statistically significant. Furthermore, the improvements measured in the groups receiving traction therapy were persistent during the follow-up period. There were no significant changes in the Oswestry Index or the EuroQol-5D-5L without VAS parameters in any of the groups.Based on our results, for patients suffering from LBP pain who underwent underwater weight bath traction therapy, there were favorable impacts on the pain levels at rest or during activity. Clinical trial registration ID: NCT03488498, April 5, 2018.

Functional Changes in Patients and Morphological Changes in the Lumbar Intervertebral Disc after Applying Lordotic Curve-Controlled Traction: A Double-Blind Randomized Controlled Study

Background and Objectives: Lumbar traction is widely used as a non-operative treatment for lumbar intervertebral disc disease. The effect of traditional traction (TT) using linear-type traction devices remains controversial for various reasons, including technical limitations. Thus, the purpose of this study was to compare the effects of the newly developed lumbar lordotic curve-controlled traction (L-LCCT) and TT on functional changes in patients and morphological changes in the vertebral disc. Materials and Methods: A total of 40 patients with lumbar intervertebral disc disease at the L4/5 or L5/S1 level as confirmed by magnetic resonance imaging were recruited and divided into two groups (L-LCCT or TT). The comprehensive health status changes of the patients were recorded using pain and functional scores (the visual analogue scale, the Oswestry Disability Index, and the Roland–Morris Disability Questionnaire) and morphological changes (in the lumbar central canal area) before and after traction treatment. Results: Pain scores were significantly decreased after traction in both groups (p < 0.05). However, functional scores and morphological changes improved significantly after treatment in the L-LCCT group only (p < 0.05). Conclusions: We suggest that L-LCCT is a viable option for resolving the technical limitations of TT by maintaining the lumbar lordotic curve in patients with lumbar intervertebral disc disease.

A theoretical study and implementation of spinal traction system with real-time biosignal feedback system

A large number of people suffer from spinal diseases, or so called back pain. Although numerous medical devices and therapies have been developed for treatment, back illnesses remain a problematic issue. Recently, the spinal traction has been reported to have a positive effect on spinal diseases, and an intelligent machine which stimulates the spine has been developed. This paper presents a theoretical study of how appropriate force can be applied from the spinal traction system to the spine. The system is designed to stimulate the spine, and the scale of force is controlled by the patient's biological status, such as blood pressure or heart rate. The theoretical force is compared to experimental results, and shows that the force is highly correlated to the theoretical derivation. The proposed approach can be utilized to customize the force on the spine based on the patients' weight and the angle of the spinal traction machine.

Esoteric Connective Tissue Therapy for chronic low back pain to reduce pain, and improve functionality and general well-being compared with physiotherapy: study protocol for a randomised controlled trial

BACKGROUND

Low back pain causes more global disability than any other condition. Once the acute pain becomes chronic, about two-thirds of sufferers will not fully recover after 1-2 years. There is a paucity of effective treatments for non-specific, chronic low back pain. It has been noted that low back pain is associated with changes in the connective tissue in the affected area, and a very low-impact treatment, Esoteric Connective Tissue Therapy (ECTT), has been developed to restore flexibility in connective tissue. ECTT uses patterns of very small, circular movements, to the legs, arms, spine, sacrum and head, which anecdotally are effective in pain relief. In an unpublished single-arm phase I/II trial with chronic pain patients, ECTT showed a 56% reduction in pain after five treatments and 45% and 54% improvements at 6 months and 7-9 years of follow-up respectively.

METHODS

The aim of this randomised controlled trial is to compare ECTT with physiotherapy for reducing pain and improving physical function and physical and mental well-being in patients with chronic low back pain. The trial will be held at two hospitals in Vietnam. One hundred participants with chronic low back pain greater than or equal to 40/100 on the visual analogue scale will be recruited and randomised to either ECTT or physiotherapy. Four weekly treatments will be provided by two experienced ECTT practitioners (Treatment Group, 40 minutes each) and hospital-employed physiotherapy nurses (Control Group, 50 minutes). The primary outcomes will be changes in pain, physical function per the Quebec Pain Functionality Questionnaire and physical and mental well-being recorded by the Short Form Health Survey (SF-36), with mixed modelling used as the primary statistical tool because the data are longitudinal. Initial follow-up will be at either 4 or 8 months, with a second follow-up after 12 months.

DISCUSSION

The trial design has important strengths, because it is to be conducted in hospitals under medical supervision, because ECTT is to be compared with a standard therapy and because the assessor and analyst are to be blinded. The findings from this trial will provide evidence of the efficacy of ECTT for chronic low back pain compared with standard physiotherapy treatment.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12616001196437 . Registered on 30 August 2016.

Mechanical effects of traction on lumbar intervertebral discs: A magnetic resonance imaging study

BACKGROUND

Although traction has long been used for treating patients with low back pain (LBP), its effects are still inconclusive mainly because of limited high-quality evidence.

OBJECTIVE

To provide evidence of the mechanism of traction on lumbar intervertebral discs.

DESIGN

A quantitative approach with a repeated measurement protocol.

METHOD

Nine participants (mean age = 22.1 ± 0.8 years) without any LBP history were recruited. Magnetic Resonance Images of the lumbar spine of each participant were recorded before and after 30 min of horizontal lying and directly after 30 min of horizontal traction of 42% body weight. The average, anterior, central, and posterior disc height and tilt angle of each lumbar disc and lumbar lordosis were measured.

RESULTS

A significant increase in the average disc height for all lumbar discs, a significant reduction of lumbar lordosis and changes in tilt angle were observed after the application of 30 min of resting followed by 30 min of traction. A significant increase in the average disc height was observed only in lower lumbar discs after 30 min of traction. The increase in the posterior disc height was more apparent than that in the anterior disc height.

CONCLUSIONS

Horizontal traction was evidently effective in increasing the disc height of lower lumbar levels, particularly in the posterior regions of the discs. Further evidence of the effects of traction of different modes, magnitudes, and durations on the change in disc height is required for proper control of traction applied to specific disc levels.

Comparison of the short-term effects of the conventional motorized traction with non-surgical spinal decompression performed with a DRX9000 device on pain, functionality, depression, and quality of life in patients with low back pain associated with lumbar disc herniation: A single-blind randomized-controlled trial

Objectives

This study aims to compare the efficiency of conventional motorized traction (CMT) with non-surgical spinal decompression (NSD) using the DRX9000™ device in patients with low back pain associated with lumbar disc herniation (LDH).

Patients and methods

Between March 2009 and September 2009, a total of 48 patients (29 females, 19 males; mean age 43.1±9.8 years; range, 18 to 65 years) were randomized into two groups. The first group (n=24) underwent CMT and the second group (n=24) underwent NSD for a total of 20 sessions over six weeks. The patients were evaluated before and after the treatment. Pain was assessed using the Visual Analog Scale (VAS), functional status using the Oswestry Disability Index (ODI), quality of life using the Short Form-36 (SF-36), state of depression mood using the Beck Depression Inventory (BDI), and the global assessment of the illness using the Patient's Global Assessment of Response to Therapy (PGART) and Investigator's Global Assessment of Response to Therapy (IGART) scales.

Results

There was no significant difference in the evaluation outcomes before the treatment between the groups. However, a statistically significant decline was found in the VAS, ODI, and BDI scores after the treatment in both groups (all p<0.001). Except for two subgroups, no significant changes were observed in the SF-36 form. Assessment of "marked improvement" was globally most frequently reported one in both groups. No significant difference was observed in the evaluation outcomes after treatment between the groups.

Conclusion

Our study results show that both CMT and NSD are effective methods in pain management and functional status and depressive mood improvement in patients with LDH, and NSD is not superior to CMT in terms of pain, functionality, depression and quality of life.

Effect of spinal decompression on the lumbar muscle activity and disk height in patients with herniated intervertebral disk

[Purpose] This study was conducted to clarify the difference in therapeutic effects between traction and decompression therapies, and their clinical therapeutic significance. [Subjects and Methods] The subjects were 31 patients aged 35 to 50 years who had unilateral or bilateral lumbar and radicular leg pain. An intervention program was implemented in 31 patients with lumbar herniated intervertebral disks. For the experimental group, 15 subjects were randomly selected to receive decompression therapy and trunk stabilization exercise. For the control group, 16 subjects were randomly selected to receive traction therapy and trunk stabilization exercise. [Results] Activities of the rectus abdominis, transverse abdominis, and external oblique muscles increased significantly in both groups. However, the activity of the erector spine muscle decreased, which was the only significant change in muscle activity among those of the other muscles in both groups. The disk herniation index in the experimental group decreased significantly in comparison with that in the control group, and the difference in the change in disk herniation index between the groups was significant. [Conclusion] Decompression therapy was demonstrated to be more effective clinically than conventional traction therapy as an intervention method for disk disease.

The Effectiveness of Mechanical Traction Among Subgroups of Patients With Low Back Pain and Leg Pain: A Randomized Trial

STUDY DESIGN

Randomized clinical trial. Background The recommended initial management strategy for patients with low back pain and signs of nerve root compression is conservative treatment, but there is little evidence to guide the most appropriate management strategy. Preliminary research suggests that a treatment protocol of mechanical traction and extension-oriented exercises may be effective, particularly in a specific subgroup of patients.

OBJECTIVE

To examine the effectiveness of mechanical traction in patients with lumbar nerve root compression and within a predefined subgroup.

METHODS

One hundred twenty patients with low back pain with nerve root compression were recruited from physical therapy clinics. Using predefined subgrouping criteria, patients were stratified at baseline and randomized to receive an extension-oriented treatment approach with or without the addition of mechanical traction. During a 6-week period, patients received up to 12 treatment visits. Primary outcomes of pain and disability were collected at 6 weeks, 6 months, and 1 year by assessors blinded to group allocation. Outcomes were examined using linear mixed-model analyses examining change over time by treatment and the interaction between treatment and subgrouping status.

RESULTS

The mean ± SD age of participants was 41.1 ± 11.3 years, median duration of symptoms was 62 days, and 57% were male. No significant differences in disability or pain outcomes were noted between treatment groups at any time point, nor was any interaction found between subgroup status and treatment.

CONCLUSION

Patients with lumbar nerve root compression presenting for physical therapy can expect significant changes in disability and pain over a 6-week treatment period. There is no evidence that mechanical lumbar traction in combination with an extension-oriented treatment is superior to extension-oriented exercises alone in the management of these patients or within a predefined subgroup of patients. The study protocol was registered with ClinicalTrials.gov (NCT00942227). Level of Evidence Therapy, level 2b.

Noninvasive and alternative management of chronic low back pain (efficacy and outcomes)

OBJECTIVES

The goal of this article is to provide a thorough literature review of available noninvasive and alternative treatment options for chronic low back pain. In particular, the efficacy of each therapy is evaluated and pertinent outcomes are described.

MATERIALS AND METHODS

A comprehensive search for available literature was done through PubMed and Cochrane data base for topics discussed in this paper.

RESULTS

Relevant current and past references were reviewed and presented to reflect the efficacy of each therapy and related outcomes.

CONCLUSIONS

There are a wide variety of noninvasive and alternative therapies for the treatment of chronic low back pain. Those with the strongest evidence in the literature for good efficacy and outcomes include exercise therapy with supervised physical therapy, multidisciplinary biopsychosocial rehabilitation, and acupuncture. Therapies with fair evidence or moderately supported by literature include yoga, back schools, thermal modalities, acupressure, and cognitive-behavioral therapy. Those therapies with poor evidence or little to no literature support include manipulation, transcutaneous electrical nerve stimulation, low-level laser therapy, reflexology, biofeedback, progressive relaxation, hypnosis, and aromatherapy. Providers delivering care for patients with chronic low back pain must carefully evaluate these available treatment options related to their efficacy or lack thereof as well as relevant outcomes.

Influences of spinal decompression therapy and general traction therapy on the pain, disability, and straight leg raising of patients with intervertebral disc herniation

[Purpose] The purpose of this study was to identify how spinal decompression therapy and general traction therapy influence the pain, disability, and straight leg raise (SLR) ability of patients with intervertebral disc herniation. [Subjects] The subjects were 30 patients with chronic lumbar pain who were divided into a spinal decompression therapy group (SDTG, n=15), and a general traction therapy group (GTTG, n=15). [Methods] The SDTG used a spinal decompression device, and the GTTG used a lumbar traction device. Both groups received conservative physical therapy three times a week for four weeks. A visual analog scale (VAS) was used to measure the degree of pain the patients with chronic lumbar pain. The Oswestry Disability Index (ODI) was used to measure the degree of functional disability. A goniometer was used to measure the patients’ SLR ability. [Results] Both SDTG and GTTG showed statistically significant decreases in VAS and ODI scores and a statistically significant increase in SLR angle. A comparison of the two groups found no statistically significant differences. [Conclusion] Spinal decompression therapy and general traction therapy are effective at improving the pain, disability, and SLR of patients with intervertebral disc herniation. Thus, selective treatment may be required.

Posterolateral transforaminal selective endoscopic diskectomy with thermal annuloplasty for discogenic low back pain: a prospective observational study

STUDY DESIGN

A prospective observational study on 113 patients with 3 years of follow-up.

OBJECTIVE

To evaluate the clinical results of therapy for discogenic low back pain (DLBP) with posterolateral transforaminal selective endoscopic diskectomy and thermal annuloplasty (PEDTA).

SUMMARY OF BACKGROUND DATA

Currently, various minimally invasive techniques are widely used to treat chronic DLBP with variable clinical outcomes. PEDTA is considered to be a novel, minimally invasive technique for treating chronic DLBP, but the evidence supporting this technique is very limited, and there are no studies demonstrating at least 3 years of follow-up.

METHODS

One hundred thirteen consecutive patients with DLBP with positive concordant pain in discography underwent PEDTA from March 2008 to March 2010. These patients included 64 males and 49 females with a mean age of 43.7 years (range, 16-75 yr). The visual analogue scale score, Japanese Orthopedic Association score, and Oswestry Disability Index were evaluated before therapy and each year after surgery. The clinical global outcomes were assessed on the basis of modified MacNab criteria at 3 years after surgery.

RESULTS

Ninety-six patients underwent a single-level procedure, and 17 patients underwent multilevel procedures. One hundred one (89.4%) cases were followed up for 3 years. There were no serious complications observed during follow-up. The success rate (excellent and good) was 73.8%. The visual analogue scale score, Japanese Orthopedic Association score and Oswestry Disability Index had significantly improved at each year after surgery (P < 0.01, compared with presurgery). The success rate in patients who underwent a single-level procedure was remarkably higher than that in patients who underwent multilevel procedures (78.2% vs. 50.0%, P = 0.041).

CONCLUSION

PEDTA presents a safe and effective treatment for carefully selected groups of patients with DLBP. Better clinical results occurred in patients with single-level discogenic pain.

Biomechanical analysis of two-step traction therapy in the lumbar spine

Traction therapy is one of the most common conservative treatments for low back pain. However, the effects of traction therapy on lumbar spine biomechanics are not well known. We investigated biomechanical effects of two-step traction therapy, which consists of global axial traction and local decompression, on the lumbar spine using a validated three-dimensional finite element model of the lumbar spine. One-third of body weight was applied on the center of the L1 vertebra toward the superior direction for the first axial traction. Anterior translation of the L4 vertebra was considered as the second local decompression. The lordosis angle between the superior planes of the L1 vertebra and sacrum was 44.6° at baseline, 35.2° with global axial traction, and 46.4° with local decompression. The fibers of annulus fibrosus in the posterior region, and intertransverse and posterior longitudinal ligaments experienced stress primarily during global axial traction, these stresses decreased during local decompression. A combination of global axial traction and local decompression would be helpful for reducing tensile stress on the fibers of the annulus fibrosus and ligaments, and intradiscal pressure in traction therapy. This study could be used to develop a safer and more effective type of traction therapy.

Belief reinforcement: one reason why costs for low back pain have not decreased

Recent figures show that there has been no change in the upward trend of direct and indirect costs for the largely benign symptom of low back pain in Western societies. This is despite greater understanding and the recommendation of a much more conservative and independent approach to its management. Moreover, in recent years, several large-scale education programs that aim to bring knowledge of the public (including general practitioners) more in line with evidence-based best practice were carried out in different countries. The hope was that the information imparted would change beliefs, ie, dysfunctional patient behavior and biomedical practice on the part of clinicians. However, these programs had no influence on behavior or costs in three out of the four countries in which they were implemented. It is argued that one reason for the overall lack of success is that it is extremely difficult to alter the potentially disabling belief among the lay public that low back pain has a structural mechanical cause. An important reason for this is that this belief continues to be regularly reinforced by the conditions of care of a range of "hands-on" providers, for whom idiosyncratic variations of that view are fundamental to their professional existence.

Caudal epidural steroid injection: a randomized controlled trial

Study design: Prospective study.

Study rationale: A recurrent phenomenon, the lifetime prevalence of low back pain has been reported as 54%–80%, while annual prevalence ranges from 15%–45%.1 It is also associated with enormous economic, societal, and health impact.2 India, being a developing country, has its problem compounded by the occupational compulsions in parts of the rural areas.3

For some interventional therapies, like epidural steroid injections, utilization rates have increased dramatically.4,5,6,7,8,9 They have become one of the most commonly performed interventions in the United States for low back pain with radiculopathy.10

Clinical question: Multiple systematic reviews,11 a meta-analysis,12 several guidelines,13 health technology assessments by insurers, and local medical review policies and coverage decisions have been published. However, controversy continues regarding the effectiveness of epidural steroid injections. In addition three types of epidurals, namely interlaminar, transforaminal, and caudal, with variable results complicate the picture for practice of interventional pain management. The underlying mechanism of action of epidurally administered steroid and local anesthetic injections is still not well understood and compounds the problem.14

Objective: To evaluate and update the effects of caudal epidural injection in the management of chronic low back pain and sciatica.

Transient adverse neurologic effects of spinal pain blocks

Objective

Chronic neck or back pain can be managed with various procedures. Although these procedures are usually well-tolerated, a variety of side effects have been reported. In this study we reviewed cases of unexpected temporary adverse events after blocks and suggest possible causes.

Methods

We reviewed the records of patients treated with spinal pain blocks between December 2009 and January 2011. The types of blocks performed were medial branch blocks, interlaminar epidural blocks and transforaminal epidural blocks. During the first eight months of the study period (Group A), 2% mepivacaine HCL and triamcinolone was used, and during the last six months of the study period (Group B), mepivacaine was diluted to 1% with normal saline.

Results

There were 704 procedures in 613 patients. Ten patients had 12 transient neurologic events. Nine patients were in Group A and one was in Group B. Transient complications occurred in four patients after cervical block and in eight patients after lumbar block. Side effects of lumbar spine blocks were associated with the concentration of mepivacaine (p<0.05). The likely causes were a high concentration of mepivacaine in five patients, inadvertent vascular injection in three patients, intrathecal leak of local anesthetics in one, and underlying conversion disorder in one.

Conclusion

Spinal pain blocks are a good option for relieving pain, but clinicians should always keep in mind the potential for development of inevitable complications. Careful history-taking, appropriate selection of the anesthetics, and using real-time fluoroscopy could help reduce the occurrence of adverse events.

Immediate changes in spinal height and pain after aquatic vertical traction in patients with persistent low back symptoms: a crossover clinical trial

OBJECTIVE

To investigate the effect of aquatic vertical traction on spinal height, pain intensity, and centralization response compared with a land-based supine flexion position for patients with low back pain and signs of nerve root compression.

DESIGN

Single-blind, repeated-measures crossover design.

SETTING

Outpatient physical therapy clinic.

SUBJECTS

Ninety-eight subjects were recruited using consecutive sampling, with 28 men and 32 women of a mean ± standard deviation (SD) age of 59.6 ± 11.6 years completing testing.

INTERVENTION

Each subject participated in 2 sessions that consisted of loaded walking for 15 minutes, followed by either 15 minutes of land-based supine position or 15 minutes of aquatic vertical traction.

MEASUREMENTS

Spinal height change, measured using a commercial stadiometer, was determined after completing loaded walking and after each intervention.

RESULTS

The mean ± SD height change of 4.99 ± 2.88 mm after aquatic vertical traction was similar to that of 4.21 ± 2.53 mm after the land-based supine flexion (P = .0969). Paired t-test indicated that both interventions resulted in significant increased height (P < .0001). Decreases in pain after aquatic intervention (2.7 ± 2.1 cm) were significantly greater than decreases after land intervention (1.7 ± 1.7 cm; P = .0034), and centralization of symptoms was more pronounced after aquatic vertical suspension compared with the supine land-based flexion condition (P < .0001). A significant correlation between height change and both pain reduction (r = 0.39; P = .001) and centralization (r = 0.29; P = .013) was observed for the aquatic intervention only.

CONCLUSION

Although both the aquatic and land interventions produced significant increases in overall spinal height, the aquatic intervention produced greater pain relief and centralization response in subjects with low back pain and signs of nerve root compression.

Restoration of disk height through non-surgical spinal decompression is associated with decreased discogenic low back pain: a retrospective cohort study

BACKGROUND

Because previous studies have suggested that motorized non-surgical spinal decompression can reduce chronic low back pain (LBP) due to disc degeneration (discogenic low back pain) and disc herniation, it has accordingly been hypothesized that the reduction of pressure on affected discs will facilitate their regeneration. The goal of this study was to determine if changes in LBP, as measured on a verbal rating scale, before and after a 6-week treatment period with non-surgical spinal decompression, correlate with changes in lumbar disc height, as measured on computed tomography (CT) scans.

METHODS

A retrospective cohort study of adults with chronic LBP attributed to disc herniation and/or discogenic LBP who underwent a 6-week treatment protocol of motorized non-surgical spinal decompression via the DRX9000 with CT scans before and after treatment. The main outcomes were changes in pain as measured on a verbal rating scale from 0 to 10 during a flexion-extension range of motion evaluation and changes in disc height as measured on CT scans. Paired t-test or linear regression was used as appropriate with p < 0.05 considered to be statistically significant.

RESULTS

We identified 30 patients with lumbar disc herniation with an average age of 65 years, body mass index of 29 kg/m2, 21 females and 9 males, and an average duration of LBP of 12.5 weeks. During treatment, low back pain decreased from 6.2 (SD 2.2) to 1.6 (2.3, p < 0.001) and disc height increased from 7.5 (1.7) mm to 8.8 (1.7) mm (p < 0.001). Increase in disc height and reduction in pain were significantly correlated (r = 0.36, p = 0.044).

CONCLUSIONS

Non-surgical spinal decompression was associated with a reduction in pain and an increase in disc height. The correlation of these variables suggests that pain reduction may be mediated, at least in part, through a restoration of disc height. A randomized controlled trial is needed to confirm these promising results.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00828880.

No effect of traction in patients with low back pain: a single centre, single blind, randomized controlled trial of Intervertebral Differential Dynamics Therapy

Low back pain (LBP) poses a significant problem to society. Although initial conservative therapy may be beneficial, persisting chronic LBP still frequently leads to expensive invasive intervention. A novel non-invasive therapy that focuses on discogenic LBP is Intervertebral Differential Dynamics Therapy (IDD Therapy, North American Medical Corp. Reg U.S.). IDD Therapy consists of intermittent traction sessions in the Accu-SPINA device (Steadfast Corporation Ltd, Essex, UK), an FDA approved, class II medical device. The intervertebral disc and facet joints are unloaded through axial distraction, positioning and relaxation cycles. The purpose of this study is to investigate the effect of IDD Therapy when added to a standard graded activity program for chronic LBP patients. In a single blind, single centre, randomized controlled trial; 60 consecutive patients were assigned to either the SHAM or the IDD Therapy. All subjects received the standard conservative therapeutic care (graded activity) and 20 sessions in the Accu-SPINA device. The traction weight in the IDD Therapy was systematically increased until 50% of a person's body weight plus 4.45 kg (10 lb) was reached. The SHAM group received a non-therapeutic traction weight of 4.45 kg in all sessions. The main outcome was assessed using a 100-mm visual analogue scale (VAS) for LBP. Secondary outcomes were VAS scores for leg pain, Oswestry Disability Index (ODI), Short-Form 36 (SF-36). All parameters were measured before and 2, 6 and 14 weeks after start of the treatment. Fear of (re)injury due to movement or activities (Tampa Scale for Kinesiophobia), coping strategies (Utrecht Coping List) and use of pain medication were recorded before and at 14 weeks. A repeated measures analysis was performed. The two groups were comparable at baseline in terms of demographic, clinical and psychological characteristics, indicating that the random allocation had succeeded. VAS low back pain improved significantly from 61 (+/-25) to 32 (+/-27) with the IDD protocol and 53 (+/-26) to 36 (+/-27) in the SHAM protocol. Moreover, leg pain, ODI and SF-36 scores improved significantly but in both groups. The use of pain medication decreased significantly, whereas scores for kinesiophobia and coping remained at the same non-pathological level. None of the parameters showed a difference between both protocols. Both treatment regimes had a significant beneficial effect on LBP, leg pain, functional status and quality of life after 14 weeks. The added axial, intermittent, mechanical traction of IDD Therapy to a standard graded activity program has been shown not to be effective.

Evidence-informed management of chronic low back pain with traction therapy

The management of chronic low back pain (CLBP) has proven to be very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

Is there a subgroup of patients with low back pain likely to benefit from mechanical traction? Results of a randomized clinical trial and subgrouping analysis

STUDY DESIGN

Randomized Clinical Trial.

OBJECTIVE

To identify a subgroup of patients with low back pain who are likely to respond favorably to an intervention including mechanical traction.

SUMMARY OF BACKGROUND DATA

Previous research has failed to find evidence supporting traction for patients with low back pain. Previous studies have used heterogeneous samples, although clinical experts tend to recommend traction for a more limited subgroup of patients with low back pain.

METHODS

Sixty-four subjects (mean age 41.1 year, 56.3% female) with low back and leg pain and signs of nerve root compression were randomized to receive a 6-week extension-oriented intervention with or without mechanical traction during the first 2 weeks. Between-group comparisons were conducted for changes in pain, disability, and fear-avoidance beliefs. Baseline variables were explored for potential as subgrouping criteria defining a subgroup of subjects likely to benefit from traction.

RESULTS

The group receiving traction showed greater improvements in disability (adjusted mean difference in Oswestry change 7.2 points) and fear-avoidance beliefs (adjusted mean difference in FABQPA change 2.6 points) after 2 weeks. There were no between-group differences after 6 weeks. Two baseline variables were associated with greater improvements with traction treatment; peripheralization with extension movements and a crossed straight leg raise.

CONCLUSION

A subgroup of patients likely to benefit from mechanical traction may exist. The results of this study suggest this subgroup is characterized by the presence of leg symptoms, signs of nerve root compression, and either peripheralization with extension movements or a crossed straight leg raise. Further research is needed to validate this finding.

Non-surgical spinal decompression therapy: does the scientific literature support efficacy claims made in the advertising media?

Background

Traction therapy has been utilized in the treatment of low back pain for decades. The most recent incarnation of traction therapy is non-surgical spinal decompression therapy which can cost over $100,000. This form of therapy has been heavily marketed to manual therapy professions and subsequently to the consumer. The purpose of this paper is to initiate a debate pertaining to the relationship between marketing claims and the scientific literature on non-surgical spinal decompression.

Discussion

Only one small randomized controlled trial and several lower level efficacy studies have been performed on spinal decompression therapy. In general the quality of these studies is questionable. Many of the studies were performed using the VAX-D^® unit which places the patient in a prone position. Often companies utilize this research for their marketing although their units place the patient in the supine position.

Summary

Only limited evidence is available to warrant the routine use of non-surgical spinal decompression, particularly when many other well investigated, less expensive alternatives are available.