Reliability of the Buttock Applied Strain Test to Diagnose Radicular Pain in Patients With Low Back Pain

Comparison of Clinical Effects and Physical Examination of Transforaminal and Caudal Steroid Injection With Targeted Catheter in Lumbar Radiculopathy: A Single-Blind Randomized Clinical Trial

BACKGROUND

Transforaminal and caudal epidural injections are two methods of steroid injection in lumbar radiculopathy. Using a targeted catheter with the possibility of accessing the involved spinal roots and steroid administration selectively next to them during the caudal procedure may achieve the benefits of both transforaminal and caudal procedures. The aim of this study was to investigate the clinical effects and physical examinations of transforaminal steroid injection compared to caudal through a targeted catheter in lumbar radiculopathy.

METHODS

Fifty patients with lumbar radiculopathy candidates for epidural steroid injection were divided into transforaminal (T) and caudal (C) groups. Steroid injection under fluoroscopic guidance was performed in group T with the transforaminal method and in group C with the caudal method using a targeted catheter for each involved spinal nerve root. Pain intensity visual analog scale (VAS), Oswestry Disability Index (ODI), daily analgesic consumption, and physical examinations on four follow-ups (before injection, second week, first and third month) were evaluated.

RESULTS

Pain score (VAS) and functional disability index (ODI) were similar in both groups, and there was no significant difference between the two groups (p > 0.05). The positive Lasègue test was significantly higher in the caudal group than in the transforaminal group only in the third month (p < 0.05). Other physical examinations in both groups did not have significant differences in all the follow-ups. Moreover, there was no difference in the amount of analgesic consumption in the two groups. No complications were observed in both groups.

CONCLUSION

This study showed that transforaminal and caudal steroid injection (with a targeted catheter) in patients with lumbar radiculopathy had similar effects in controlling pain and improving functional disability of patients in the short term. Cases of recurrence of positive Lasègue test in physical examinations in the long term (third month) in the caudal group may indicate the preference of the transforaminal approach.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials (IRCT) number: IRCT20111102007984N31.

The Occipital Nerves Applied Strain Test to Support Occipital Neuralgia Diagnosis

INTRODUCTION

Occipital neuralgia (ON) is a disabling cephalalgia form with demanding diagnostic workflow. We report the description and reliability analyses of the occipital nerves-applied strain (ONAS) test for occipital neuralgia (ON) early-stage diagnosis in cephalalgia patients.

METHODS

In a retrospective and observational study, we evaluated, among n = 163 consecutive cephalalgia patients, the sensitivity, specificity, and prior probability [positive (PPV) and negative (NPV) predictive values] of the ONAS test against two reference tests (occipital nerve anesthetic block and the painDETECT questionnaire). Multinomial logistic regression (MLR) and χ2 analyses verified the ONAS test outcome's dependence upon independent variables (gender, age, pain site, block test, and painDETECT outcomes). We assessed inter-rater agreement with Cohen's kappa statistic.

RESULTS

ONAS test showed sensitivity and specificity of 81 and 18%, respectively, against the painDETECT and of 94 and 46%, respectively, against the block test. PPV was > 70% against both tests, while NPV was 81% against the block test and 26% against the painDETECT. Interrater agreement Cohen's kappa was excellent. Significant association (χ2 analyses) and relationship (MLR) were found only between ONAS test and pain site but not with the other independent predictors.

CONCLUSIONS

The ONAS test showed satisfactory reliability among cephalalgia patients; thus, it might be considered a valuable early stage tool for ON diagnosis in these patients.

Evidence for the BUAS-test ability to diagnose lumbar radicular pain

BACKGROUND

Differential diagnosis of low back pain (LBP) is complex and a prominent issue at all health-care levels; guidance may come from patients' history cues and clinical examination signs. Human and animal studies report that diagnosis of lumbar radicular pain (LRP) may come from evaluating subjective responses of injured lumbar nerves to a strain applied at the buttock. The Buttock Applied Strain (BUAS-test) test may guide the differential diagnosis of LBP. Following an ex-adiuvantibus criterion, clinical improvement of LRP, diagnosed with the BUAS-test and congruently treated, may support this test diagnostic ability.

METHODS

Among 258 LRP patients, who, upon first visit (V1), tested positive on the BUAS-test (with/without positive Straight Leg Raising Test, SLRT), the effect of gabapentin prescription on painDETECT (PD) questionnaire and Brief Pain Inventory (BPI) outcomes was quantified in the follow-up visit (V2). To support BUAS-test diagnostic ability, we hypothesized that, at V2, >50% of the sample would present negative PD outcome, significant (t-test) and ⩾2 points V2-V1 differences for each of the BPI-item's score. We used multinomial logistic regression (MLR) and χ2 analyses to evaluate the PD-V2 outcomes' dependence upon independent variables.

RESULTS

Of the sample, 77% reported a negative PD-V2 outcome. V2-V1 differences of all BPI items were significant and >2 points. PD-V2 outcomes showed significant associations with SLRT-V1 and PD-V1, respectively, but not with gender, age group or pain site. MLR showed a significant relationship between SLRT-V1 and PD-V2 outcomes.

CONCLUSION

Among LRP patients, diagnosed by the BUAS-test and treated with gabapentin, all prespecified endpoints were reached. These results may be considered a piece of ex-adiuvantibus evidence for the BUAS-test ability to diagnose LRP. While positive BUAS-test implies potential LRP, the co-presence with positive SLRT may imply a severer LRP condition. Further prospective research, in different settings and direct clinical measures, is needed.

Combination of Gluteal Trigger Points Dry Needling and Percutaneous Endoscopic Lumbar Discectomy for Complex Low Back-Related Leg Pain

Purpose

Causes of low back-related leg pain (LBLP) can be complex and diverse. A detailed medical history, physical examination, laboratory tests, and imaging are necessary to accurately distinguish the pathomechanisms of LBLP and determine the most appropriate treatment.

Case

In this study, we report the first documented case in which the combination of dry needling (DN) and percutaneous endoscopic lumbar discectomy (PELD) was used for a patient with active myofascial trigger points (MTrPs) in the gluteus minimus muscle as well as L3-4 lumbar disc herniation (LDH). This 63-year-old woman complained of LBLP for 3 months. After careful examination and analysis, we determined this pain originated from two active MTrPs in the gluteal region and not LDH in L3-4. We first performed MTrPs DN, and the patient's LBLP was relieved completely. We then performed PELD at the L3-4 level for residual numbness on the medial and anterior aspect of the left lower limb. Finally, the patient received a satisfactory result.

Conclusion

The gluteal MTrPs test may be used as a routine examination for patients with LBLP, especially when clinical findings are discordant with imaging results.