Pain patterns and descriptions in patients with radicular pain: does the pain necessarily follow a specific dermatome?

A Meta-analysis Exploring the Efficacy of Neuropathic Pain Medication for Low Back Pain or Spine-Related Leg Pain: Is Efficacy Dependent on the Presence of Neuropathic Pain?

BACKGROUND AND OBJECTIVE

Highly variable pain mechanisms in people with low back pain or spine-related leg pain might contribute to inefficacy of neuropathic pain medication. This meta-analysis aimed to determine how neuropathic pain is identified in clinical trials for people taking neuropathic pain medication for low back pain or spine-related leg pain and whether subgrouping based on the presence of neuropathic pain influences efficacy.

METHODS

EMBASE, MEDLINE, Cochrane Central, CINAHL [EBSCO], APA PsycINFO, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry were searched from inception to 14 May, 2024. Randomized and crossover trials comparing first-line neuropathic pain medication for people with low back pain or spine-related leg pain to placebo or usual care were included. Two independent authors extracted data. Random-effects meta-analyses of all studies combined, and pre-planned subgroup meta-analyses based on the certainty of neuropathic pain (according to the neuropathic pain Special Interest Group [NeuPSIG] neuropathic pain grading criteria) were completed. Certainty of evidence was judged using the grading of recommendations assessment development and evaluation [GRADE] framework.

RESULTS

Twenty-seven included studies reported on 3619 participants. Overall, 33% of studies were judged unlikely to include people with neuropathic pain, 26% remained unclear. Only 41% identified people with possible, probable, or definite neuropathic pain. For pain, general analyses revealed only small effects at short term (mean difference [MD] - 9.30 [95% confidence interval [CI] - 13.71, - 4.88], I2 = 87%) and medium term (MD - 5.49 [95% CI - 7.24, - 3.74], I2 = 0%). Subgrouping at short term revealed studies including people with definite or probable neuropathic pain showed larger effects on pain (definite; MD - 16.65 [95% CI - 35.95, 2.65], I2 = 84%; probable; MD - 10.45 [95% CI - 14.79, - 6.12], I2 = 20%) than studies including people with possible (MD - 5.50 [95% CI - 20.52, 9.52], I2 = 78%), unlikely (MD - 6.67 [95% CI - 10.58, 2.76], I2 = 0%), or unclear neuropathic pain (MD - 8.93 [95% CI - 20.57, 2.71], I2 = 96%). Similarly, general analyses revealed negligible effects on disability at short term (MD - 3.35 [95% CI - 9.00, 2.29], I2 = 93%) and medium term (MD - 4.06 [95% CI - 5.63, - 2.48], I2 = 0%). Sub-grouping at short term revealed larger effects in studies including people with definite/probable neuropathic pain (MD - 9.25 [95% CI - 12.59, - 5.90], I2 = 2%) compared with those with possible/unclear/unlikely neuropathic pain (MD -1.57 [95% CI - 8.96, 5.82] I2 = 95%). Medium-term outcomes showed a similar trend, but were limited by low numbers of studies. Certainty of evidence was low to very low for all outcomes.

CONCLUSIONS

Most studies using neuropathic pain medication for low back pain or spine-related leg pain fail to adequately consider the presence of neuropathic pain. Meta-analyses suggest neuropathic pain medication may be most effective in people with low back pain or spine-related leg pain with a definite/probable neuropathic pain component. However, the low to very low certainty of evidence and poor identification of neuropathic pain in most studies prevent firm recommendations.

Foot pressure transfers are altered in lumbar radiculopathy but reversible after surgery: a prospective, pedobarography study

BACKGROUND CONTEXT

Patients with lower lumbar stenosis and disc herniation report disability in standing and ambulation, despite normal neurological examination. The L5 and S1 nerve roots support the entire motor and sensory function of the foot, and their radiculopathy can affect foot loading during standing and walking. This has not been quantified before.

PURPOSE

To quantify alterations in static and dynamic foot pressure transfers in patients with lower lumbar nerve root compression, and document any beneficial effects of surgical decompression.

STUDY DESIGN

Prospective, case-control study.

PATIENT SAMPLE

Cases-Patients with unilateral radiculopathy (L5/S1) with normal neurology (n=50); Controls - Healthy volunteers (n=50).

METHODS

The volunteers and patients underwent pedobarographic analysis during standing (static) and walking (dynamic), and fifteen (12 dynamic and three static) parameters were documented. The patient's preoperative values were compared with that of the healthy volunteers. All the 50 patients underwent surgical decompression, and clinical outcome measures (VAS/ODI at 3 months) were documented. Pedobarographic analysis was repeated in the postoperative period (48 hours) and 3-month follow-up and compared with the preoperative scores.

RESULTS

In healthy controls, the mean values of all 15 parameters were comparable between the right and the left side (p>.05). When compared to controls, the patients had significantly lower maximum foot loads (p=.01) and average foot loads (p=.05) on the affected side during walking indicating lesser load transmission, in the preoperative period. Within the affected foot, the load transfer was higher on the first metatarsal/ medial arch while significantly less on the lateral metatarsals (p=.04). The percentage load on whole foot and forefoot was significantly less on standing (p=.01). Significant improvements were noted in the postoperative period, especially in the maximum foot surface area (p=.01), maximum and average foot loads, and improved weight transfers on lateral arch and forefoot (p=.02). The load on whole foot increased significantly from 46.1%±5.5% (preoperative) to 48.1%±5.5% (postoperative) and 49.9%±3.3% at follow-up (p=.01).

CONCLUSION

This is the first study using pedobarography to document altered foot pressure patterns during ambulation in patients with disc herniation and stenosis. Decreased load transfer, asymmetrical and unphysiological distribution of pressures on the affected foot were observed during weight bearing, which improved after surgical decompression.

Rethinking neck-related arm pain: hypothetical clinical scenarios to differentiate the underlying IASP-defined pain mechanisms

Neck-related arm pain is frequently encountered in clinical settings, yet its underlying pain mechanisms remain elusive. While such pain radiating from the neck to the arm is often attributed to injuries or diseases of the nervous system (neuropathic pain), it can also arise from nociceptive (referred) or nociplastic sources. Regrettably, patients exhibiting this specific pain distribution are frequently diagnosed with varying terms, including 'cervicobrachialgia', 'cervicobrachial neuralgia', 'cervicobrachial pain syndrome', and 'cervical radiculopathy'. The ambiguity surrounding these diagnostic labels complicates the clinical reasoning process. It is imperative for clinicians to discern and comprehend the dominant pain mechanism. Three distinct hypothetical clinical scenarios depict patients with almost identical pain distribution but divergent dominant pain mechanisms. Within these scenarios, both subjective and objective examinations are employed to elucidate the dominant pain mechanism associated with neck-related arm pain: nociceptive, neuropathic, and nociplastic. Furthermore, clinicians must remain aware that the dominant pain mechanism can evolve over time.

Systemic low-grade C-reactive protein is associated with proximal symptom spread in carpal tunnel syndrome

Introduction

Neuropathic pain is a highly prevalent condition associated with persistent disability. Some patients with neuropathic pain experience symptom spread outside neuroanatomical boundaries; these patients report more severe sensory symptoms and greater disability. However, the mechanisms behind such symptom spread are not fully understood.

Objective

We used pre-surgical carpal tunnel syndrome (CTS) as a human model system of neuropathic pain to identify differences in the concentration of serologic inflammatory mediators between patients with CTS with territorial symptoms and those with proximal symptom spread to either the elbow or shoulder/neck.

Methods

We performed a post-hoc analysis, comparing levels of serologic inflammatory mediators in a discovery cohort among 3 symptoms spread profiles (n = 55; n = 25 no spread, n = 21 spread to elbow, n = 9 spread to shoulder/neck). We then de-novo analysed the significantly dysregulated mediators in an independent validation cohort (n = 72; n = 34 no spread, n = 16 spread to elbow, n = 22 spread to shoulder/neck).

Results

The discovery cohort revealed higher serum concentrations of C-reactive protein (CRP) and interleukin-6 in patients with any symptom spread proximal to the wrist; interferon-γ was higher in patients with symptom spread to the elbow compared with those without proximal spread. The validation study replicated the association of higher CRP concentrations in patients with proximal spread to the elbow (no spread: median [interquartile range] 2.5 [5.4]; spread to elbow 6.2 [4.6]; spread to shoulder/neck 2.6 [3.7], P = 0.006). No other markers replicated in the validation cohort.

Conclusions

Our findings suggest that proximal symptom spread in the context of neuropathic symptoms is associated with low-grade inflammation.

Could pain change position choice? Comparison of pain level, analgesic requirement and hospitalization time in supine and prone percutaneous nephrolithotomy

PURPOSE

Investigation of how position affects postoperative pain levels and hospitalization in patients undergoing percutaneous nephrolithotomy (PNL) surgery.

METHODS

Between August 2019 and December 2022, a total of 156 patients who underwent prone (pPNL) and supine percutaneous nephrolithotomy (sPNL) due to kidney stones were included in the study. Demographic data, preoperative CT scans, laboratory results, transfusion rates, operation durations, complication rates, stone-free rates, analgesic use, nephrostomy removal time, hospitalization duration, fluoroscopy time, hemoglobin decrease and postoperative Visual Analog Scale (VAS) scores were evaluated for all patients. By comparing these data between the sPNL and pPNL groups, the effect of position selection in PNL on pain control, analgesic requirement, and hospitalization duration was examined.

RESULTS

In the comparison of the pPNL and sPNL groups, there was a significant difference between the two groups in body mass index, hounsfield unit, complication rate, analgesic rate, nephrostomy remove time, hospitalization time, operation time, fluoroscopy time and VAS score (p = 0.025, p < 0.001, p = 0.012, p = 0.012, p < 0.001, p < 0.001, p < 0.001, p < 0.001 and p < 0.001, respectively).

CONCLUSION

The shorter operation and hospitalization time in the sPNL group could be attributed to performing surgeries in a physiological position. Additionally, sPNL seems advantageous in terms of patients' pain levels, hospitalization time and VAS scores. One reason for this could be the different areas of access in sPNL and pPNL, which may correspond to different dermatome regions. Considering the low level of pain and reduced analgesic usage, sPNL appears to be advantageous.

Understanding How Patients With Lumbar Radiculopathy Make Sense of and Cope With Their Symptoms

Lumbar radiculopathy, characterized by pain radiating along a nerve root, significantly diminishes the quality of life due to its neuropathic nature. Patients' understanding of their illness and the coping strategies they employ directly influence how they manage their condition. Understanding these illness representations from the patient's perspective is crucial for healthcare providers seeking to optimize treatment outcomes. This study adopted a qualitative interpretive/constructive paradigm to explore this dynamic. A qualitative evidence synthesis approach, utilizing best-fit framework synthesis for data extraction, was applied to analyze primary qualitative studies focused on patient experiences with lumbar radiculopathy. Using SPiDER (Sample, Phenomenon of interest, Design, Evaluation, Research type) to guide the search strategy, extracted data was mapped against the Common-Sense Model of Self-Regulation (CSM) framework. Sixteen studies, with moderate to minor methodological quality concerns, were included in the analysis. Data mapping across CSM domains generated 14 key review findings. Results suggest that patients with high-threat illness representations often exhibit maladaptive coping behaviors (e.g., activity avoidance) driven by emotional responses. In contrast, problem-solving techniques appear to contribute to positive outcomes (e.g., exercise adherence and effective self-management) in patients who perceive their condition as less threatening. These findings highlight the potential benefits of interventions designed to reduce perceived threat levels and enhance self-efficacy in patients with lumbar radiculopathy, leading to improved self-management and ultimately better health outcomes.

Clinical Outcomes of Percutaneous Transforaminal Endoscopic Discectomy Assisted with Selective Nerve Root Block for Treating Radicular Pain with Diagnostic Uncertainty in the Elderly

Purpose

To investigate the clinical outcomes of percutaneous transforaminal endoscopic discectomy assisted with selective nerve root block for treating radicular pain with diagnostic uncertainty in the elderly.

Methods

A total number of 36 elderly patients were included in the study. Clinical outcomes collected for analysis include operative time, hospital stay time, Visual Analog Scale, and Oswestry Disability Index before and after the surgery, the global outcome based on the Macnab outcome criteria.

Results

Seventeen males and nineteen females with a mean age of 73.72 ± 7.15 were included in this study. Radicular pain was the main complaint of all the patients with the least symptom duration of two months. Radiological findings showed that 80.6% of the patients with multilevel disc herniation, 16.7% received lumbar fusion surgery before, and 8.3% with degenerative scoliosis. Besides, 69.4% of the patients have at least one comorbidity. 85.4% of the patients showed a positive response to selective nerve root block, and 91.6% of the patients reported a favorable outcome at the last follow-up. The mean value of pre-operative leg pain was 7.56 ± 0.74 and dramatically decreased after surgery (2.47 ± 0.81, P < 0.001). Besides, the mean value of Oswestry Disability Index decreased from 43.03 ± 4.43 to 5.92 ± 5.24 (P < 0.001) one year after the surgery.

Conclusion

Multilevel degeneration of the lumbar spine is common in elderly patients. Identifying the responsible segment and decompressing the nerve root through minimally invasive surgery can provide a satisfactory clinical outcome for those with radicular pain as their primary complaint. And selective nerve root block is a reliable diagnostic tool for those with an ambiguous diagnosis.

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

ABSTRACT

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

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

STUDY DESIGN

Systematic review.

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

A Propensity Score-matched Analysis of Clinical Outcomes Between Single-level and Multilevel Intervertebral Decompression for Cervical Radiculopathy

STUDY DESIGN

Retrospective multicenter study with propensity score matching.

OBJECTIVE

To compare the clinical outcomes of single-level and multilevel intervertebral decompression for cervical degenerative radiculopathy.

SUMMARY OF BACKGROUND DATA

In patients with cervical radiculopathy, physical examination findings are sometimes inconsistent with imaging data. Multilevel decompression may be necessary for multiple foraminal stenosis. Additional decompression is more invasive yet expected to comprehensively decompress all suspected nerve root compression areas. However, the surgical outcomes of this approach compared with that of single-level decompression remain unknown.

MATERIALS AND METHODS

The data of patients with spinal surgery for pure cervical radiculopathy were collected. Patients were categorized into the single-level (SLDG) or multilevel (MLDG) intervertebral decompression group at C3/C4/C5/C6/C7/T1. Demographic data and patient-reported outcome scores, including the Neck Disability Index (NDI) and Numerical Rating Scale (NRS) scores for pain and numbness in the neck, upper back, and arms, were collected. The NDI improvement rates and changes in NRS scores were analyzed one year postoperatively at patient-reported outcome evaluation. Propensity score matching was performed to compare both groups after adjusting for baseline characteristics, including the preoperative NDI and NRS scores.

RESULTS

Among the 357 patients in this study, SLDG and MLDG comprised 231 and 126 patients, respectively. Two groups (n=112, each) were created by propensity score matching. Compared with the MLDG, the SLDG had a higher postoperative NDI improvement rate ( P =0.029) and lower postoperative arm numbness NRS score ( P =0.037). Other outcomes tended to be more favorable in the SLDG than in the MLDG, yet no statistical significance was detected.

CONCLUSIONS

In patients with cervical radiculopathy, the surgical outcomes of the SLDG showed better improvement in clinical outcomes than those of the MLDG. Numbness remained on the distal (arms) rather than the central (neck and upper back) areas in patients receiving multilevel decompression.

Symptom descriptors and patterns in lumbar radicular pain caused by disc herniation: a 1-year longitudinal cohort study

OBJECTIVE

The objective of the present study was to explore the diversity, quality, severity and distribution of symptoms in patients with radicular pain and a lumbar disc herniation.

DESIGN

Longitudinal cohort study.

SETTING

Hospital-based back clinic.

PARTICIPANTS

Ninety patients referred to secondary healthcare with (a) low back-related leg pain, (b) age between 18 and 65 years and (c) MRI confirmed lumbar disc herniation at a relevant side and level.

OUTCOME MEASURES

Neuropathic pain symptoms were assessed using the Short-Form McGill Pain Questionnaire-2 (SF-MPQ-2) and the painDETECT Questionnaire. In a subsample classified with neuropathic pain, in-depth interviews were performed, and symptomatic areas were drawn on standardised body charts.

RESULTS

At baseline, the most frequently used painDETECT symptom descriptor was numbness sensation, reported by 94%, followed by sudden pain attacks and tingling or prickling. The mean (SD) SF-MPQ-2 score (0-10) for aching pain was 5.9 (2.8); numbness 4.3 (3.3); tingling 4.0 (3.4); burning 2.6 (3.1); pain caused by light touch 1.5 (2.6). Leg pain was rated as extremely bothersome by 73%, numbness and tingling by 38%, weakness by 24% and back pain by 17%. In the subsample (n=52), deep-lying pain and non-painful abnormal sensations were frequent, at 71% and 85%. Drawings demonstrated substantial overlap between symptoms from compromised L5 and the S1 nerve roots. Painful and non-painful symptoms improved at approximately the same rate. At the 1-year follow-up, 45% (14/31) of patients who had received disc surgery, and 34% (18/53) of those who had received conservative treatment reported no bothersome back pain, leg pain, numbness/tingling or weakness.

CONCLUSION

Patients reported several highly bothersome symptoms, but not all are described as painful. The overall symptom profile of lumbar disc-related radicular pain differs from other neuropathic pain conditions with limited allodynia and thermal hyperalgesia. Symptomatic areas for the L5 and S1 nerve roots have a large overlap.

Reliability and Diagnostic Accuracy of Standard Dermatomes and Myotomes for Determining the Pathologic Level in Surgically Verified Patients With Cervical Radiculopathy

OBJECTIVE

This study aimed to investigate the reliability and diagnostic accuracy of typical dermatomes and myotomes for determining the pathologic level in surgically verified patients with cervical radiculopathy.

METHODS

Patients who underwent single-level surgery due to cervical radiculopathy with at least a 60% reduction in preoperative symptoms or recovery of muscle power after surgery were included. The observed clinical symptoms (pain, paresthesia, motor weakness) were compared to those of typical cervical dermatomes and myotomes.

RESULTS

Among the 227 patients reviewed, 142 (62.6%) had a standard dermatomal pattern, and 74 of 110 (67.3%) had a standard myotomal pattern. The myotome of C5/6 radiculopathy showed much more variance than those of other cervical segments. Among the patients with severe motor weakness (muscle strength ≤ grade 3 or obvious muscle atrophy), all those with involvement of root C5, C7, and C8 showed a typical pattern (C4/5: 13 of 13 patients, C6/7: 5 of 5 patients, C7/T1: 3 of 3 patients), while only 2 of the 6 patients (33.3%) with severe motor weakness caused by C5/6 radiculopathy fit the typical pattern.

CONCLUSION

Among various symptoms, cervical myotome is of great value in determining the pathological level. However, it should be noted that there is high variability in human dermatomes and myotomes, especially for motor weakness due to C6 root compression, which is more variable than others.

Musculoskeletal mimics of cervical radiculopathy

Musculoskeletal mimics of cervical radiculopathy will be explored in this AANEM monograph. A review of the literature and textbooks was conducted. Musculoskeletal cervical radiculopathy mimics include: (1) head/neck pain, such as neck tension, cervicogenic headache, and temporomandibular disorder; (2) referred pain from shoulder pathology, such as rotator cuff tears/impingement; (3) elbow region abnormalities, including medial/lateral epicondylitis; (4) wrist/hand conditions, such as DeQuervain's tenosynovitis and intersection syndrome; (5) muscle connective tissue disorders, including myofascial trigger points; (6) conditions that have decreased range of motion, including frozen shoulder and rounded shoulders with tight pectoral/scalene muscles; (7) conditions with joint hyperlaxity and instability, as seen in post-stroke shoulder subluxation; (8) vascular conditions, such as thoracic outlet syndrome; and (9) autonomic controlled soft tissue changes associated with complex regional pain syndrome. Formulating a differential diagnosis and recognizing mimics of cervical radiculopathy can decrease the time between symptom onset and diagnosis/treatment plan.

Assessing Pain Research: A Narrative Review of Emerging Pain Methods, Their Technosocial Implications, and Opportunities for Multidisciplinary Approaches

Pain research traverses many disciplines and methodologies. Yet, despite our understanding and field-wide acceptance of the multifactorial essence of pain as a sensory perception, emotional experience, and biopsychosocial condition, pain scientists and practitioners often remain siloed within their domain expertise and associated techniques. The context in which the field finds itself today-with increasing reliance on digital technologies, an on-going pandemic, and continued disparities in pain care-requires new collaborations and different approaches to measuring pain. Here, we review the state-of-the-art in human pain research, summarizing emerging practices and cutting-edge techniques across multiple methods and technologies. For each, we outline foreseeable technosocial considerations, reflecting on implications for standards of care, pain management, research, and societal impact. Through overviewing alternative data sources and varied ways of measuring pain and by reflecting on the concerns, limitations, and challenges facing the field, we hope to create critical dialogues, inspire more collaborations, and foster new ideas for future pain research methods.

Associations between Patient Report of Pain and Intervertebral Foramina Changes Visible on Axial-Loaded Lumbar Magnetic Resonance Imaging

The intervertebral foramen may influence spinal nerve roots and, therefore, be related to the corresponding dermatomal pain. In vivo evaluation of the intervertebral foramen–dermatome relationship is essential for understanding low back pain (LBP) pathophysiology. The study aimed to correlate the lumbar MRI unloaded-loaded foraminal area changes with dermatomal pain in the patient’s pain drawings. Dynamic changes of the dermatomal pain distribution related to the intervertebral foramen area changes between quantitative conventional supine MRI (unloaded MRI) and axial-loading MRI (alMRI) were analyzed. The MRI axial-loading intervertebral foramen area changes were observed, and the most significant effect of reducing the foraminal area (−6.9%) was reported at levels of L2–L3. The incidence of pain in the dermatomes increases linearly with the spine level, from 15.6% at L1 to 63.3% at L5 on the right and from 18.9% at L1 to 76.7% at L5 on the left. No statistically significant effect of changes in the intervertebral foramen area on the odds of pain along the respective dermatomes was confirmed. Changes in the foraminal area were observed between the unloaded and loaded phases, but differences in area changes between foramen assigned to painful dermatomes and foramen assigned to non-painful dermatomes were not significant.

The Hip-Spine Connection: How to Differentiate Hip Conditions From Spine Pathology

Practitioners treating spine pathology commonly encounter patients with hip pain. These patients frequently manifest groin, buttock, trochanteric, or knee pain. Complex biomechanical interaction between the axial and the appendicular skeleton may result in compensatory adaptation. Cross-innervation of the hip and surrounding tissues may make diagnosis of the primary source difficult, leading to delayed diagnosis. This review elucidates the interaction between the hip and the spine and can assist clinicians in recognizing the hip as a potential source of pain. Diagnostic guidelines enabling a streamlined workup of patients presenting with confusing symptoms related to the hip that masquerade as a spine disorder are presented. [Orthopedics. 2021;44(6):e699-e706.].

When Clinical Diagnosis Differs From Advanced Imaging: A Case Series of Disc Herniations Causing Radiculopathy and Review of Aberrant Nerve Root Innervation

ABSTRACT

Radiculopathy is diagnosed using a combination of history, physical examination, and imaging. Unfortunately, well-established dermatomal and myotomal maps are an oversimplification of the convoluted nature of spinal sensory and motor innervation. When clinical presentation and imaging seemingly contradict one another, it is important to consider variant innervation patterns. This article presents three patients with objective dermatomal and/or myotomal deficits due to disc herniations whose clinical presentations are "textbook" for nerve root pathology that is adjacent to the nerve root that is actually compromised. In addition, the literature is reviewed to discuss the history of dermatomal and myotomal maps, the effectiveness of a clinician's ability to determine the precise pathologic disc and nerve root level in patients presenting with radiculopathy, and anatomical explanations as to why inconsistencies such as those seen in the patients in these cases exist.

[Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management : German version]

Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potenzial mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.

HDAC6: A Key Link Between Mitochondria and Development of Peripheral Neuropathy

Peripheral neuropathy, which is the result of nerve damage from lesions or disease, continues to be a major health concern due to the common manifestation of neuropathic pain. Most investigations into the development of peripheral neuropathy focus on key players such as voltage-gated ion channels or glutamate receptors. However, emerging evidence points to mitochondrial dysfunction as a major player in the development of peripheral neuropathy and resulting neuropathic pain. Mitochondrial dysfunction in neuropathy includes altered mitochondrial transport, mitochondrial metabolism, as well as mitochondrial dynamics. The mechanisms that lead to mitochondrial dysfunction in peripheral neuropathy are poorly understood, however, the Class IIb histone deacetylase (HDAC6), may play an important role in the process. HDAC6 is a key regulator in multiple mechanisms of mitochondrial dynamics and may contribute to mitochondrial dysregulation in peripheral neuropathy. Accumulating evidence shows that HDAC6 inhibition is strongly associated with alleviating peripheral neuropathy and neuropathic pain, as well as mitochondrial dysfunction, in in vivo and in vitro models of peripheral neuropathy. Thus, HDAC6 inhibitors are being investigated as potential therapies for multiple peripheral neuropathic disorders. Here, we review emerging studies and integrate recent advances in understanding the unique connection between peripheral neuropathy and mitochondrial dysfunction through HDAC6-mediated interactions.

Larger pain extent is associated with greater pain intensity and disability but not with general health status or psychosocial features in patients with cervical radiculopathy

Pain as a result of cervical radiculopathy (CR) can be widespread, nondermatomal and individually specific, but the association between pain extent and other clinical features has never been explored. The objective of this study is to investigate whether pain extent relates to clinical variables including pain intensity in addition to health indicators including disability, general health, depression, somatic anxiety, coping strategies or self-efficacy.An observational cohort study was conducted. Participants were recruited from 4 hospital spinal centres in Sweden. Pain extent was quantified from the pain drawings of 190 individuals with cervical disc disease, verified with magnetic resonance imaging (MRI) and compatible with clinical findings (examined by a neurosurgeon), that show cervical nerve root compression. Pain extent was evaluated in relation to neck pain, arm pain, and headache intensity. Multiple linear regression analysis were then used to verify whether pain extent was associated with other health indicators including disability, health-related quality of life, depression, somatic anxiety, coping strategies and self-efficacy.Pain extent was directly related to neck, arm and headache pain intensity (all P < .01). Multiple linear regression revealed that pain extent was significantly associated only to the level of perceived disability (P < .01).Increased pain extent in people with CR is associated with higher headache, neck and arm pain intensity, and disability but not measures of general health, depression, somatic anxiety, coping strategies or self-efficacy.

The Necessity of Upper Extremity Neurologic Examination while Evaluating Breast Pain

Introduction

Breast pain is one of the most frequent complaints and occurs in 45-69% of all women. Cervical disc herniation is a common cause of cervical radiculopathy with an incidence rate of 18.6 per 100,000, and it should be considered as a cause of breast pain.

Objective

To identify the extent to which upper extremity neurologic findings and cervical root disorders accompany breast pain.

Methods

We prospectively collected clinical features of patients with breast pain. An upper extremity neurologic examination was performed in patients and controls. Patients who had neurologic findings underwent cervical spine magnetic resonance imaging (MRI) to identify cervical root disorders.

Results

Out of the 554 participants, 233 had breast pain, and 321 were controls. Women with breast pain had more numbness (116 [49.8%] vs. 104 [32.4%], p < 0.001) and more dysesthesia (36 [15.5%] vs. 17 [5.3%], p < 0.001) than the controls, but they had similar upper extremity weakness (10 [4.3%] vs. 14 [4.4%], p > 0.05). The number of women with one neurologic finding was significantly greater in the group with breast pain (119 [51.1%] vs. 111 [34.6%], p < 0.001). Ninety (16.2%) patients underwent a cervical vertebra MRI, which showed that 86 (95.6%) patients had cervical root disorders including 21 (23.3%) cases of bulging, 9 (10%) of annular tear, and 56 (62.2%) of central disc protrusion; 4 (4.4%) patients had normal findings. The multivariate logistic regression analysis revealed that age was the only significant predictor of neurologic findings in patients with breast pain (p < 0.05, OR: 1.02, CI: 1.002-1.053).

Conclusions

Cervical root disorders should be considered as a cause of extramammary breast pain.

Use of Neurodynamic or Orthopedic Tension Tests for the Diagnosis of Lumbar and Lumbosacral Radiculopathies: Study of the Diagnostic Validity

BACKGROUND

Lumbar radiculopathy is a nerve root disorder whose correct diagnosis is essential. The objective of the present study was to analyze the reliability diagnostic validity of eight neurodynamic and/or orthopedic tension tests using magnetic resonance imaging as the Gold Standard.

METHODS

An epidemiological study of randomized consecutive cases which was observational, descriptive, transversal, double blinded and was conducted following the Standards for Reporting Diagnostic accuracy studies (STARD) declaration. The sample size was 864 participants. Internal and external validity (CI = 95%) and reliability, were calculated for all tests performed independently. The diagnostic validity of the combined and multiple tests in parallel was also calculated.

RESULTS

The analysis indicated that only two tests performed independently had external validity, but neither had reliability or precision. The Straight Leg Raise test and the Bragard test performed in a multiple parallel way showed high sensitivity (97,40%), high negative predictive value (PV- 96,64%) and external validity (Likelihood Ratio- 0,05). The combined test of the Slump test and the Dejerine's triad had internal and external validity.

CONCLUSIONS

The Straight Leg Raise test and the Bragard test performed in a multiple parallel way and the combined test of the Slump Test and the Dejerine's triad have clinical validity to discard lumbar or lumbar-sacral radiculopathy.

Physiotherapy for people with painful peripheral neuropathies: a narrative review of its efficacy and safety

Pharmacological treatment for peripheral neuropathic pain has only modest effects and is often limited by serious adverse responses. Alternative treatment approaches including physiotherapy management have thus gained interest in the management of people with peripheral neuropathies. This narrative review summarises the current literature on the efficacy and safety of physiotherapy to reduce pain and disability in people with radicular pain and chemotherapy-induced peripheral neuropathy, 2 common peripheral neuropathies. For chemotherapy-induced peripheral neuropathy, the current evidence based on 8 randomised controlled trials suggests that exercise may reduce symptoms in patients with established neuropathy, but there is a lack of evidence for its preventative effect in patients who do not yet have symptoms. For radicular pain, most of the 21 trials investigated interventions targeted at improving motor control or reducing neural mechanosensitivity. The results were equivocal, with some indication that neural tissue management may show some benefits in reducing pain. Adverse events to physiotherapy seemed rare; however, these were not consistently reported across all studies. Although it is encouraging to see that the evidence base for physiotherapy in the treatment of peripheral neuropathic pain is growing steadily, the mixed quality of available studies currently prevents firm treatment recommendations. Based on promising preliminary data, suggestions are made on potential directions to move the field forward.

B12 as a Treatment for Peripheral Neuropathic Pain: A Systematic Review

Neuropathic pain describes a range of unpleasant sensations caused by a lesion or disease of the somatosensory nervous system. The sensations caused by neuropathic pain are debilitating and improved treatment regimens are sought in order to improve the quality of life of patients. One proposed treatment for neuropathic pain is vitamin B12, which is thought to alleviate pain by a number of mechanisms including promoting myelination, increasing nerve regeneration and decreasing ectopic nerve firing. In this paper, the evidence for B12 as a drug treatment for neuropathic pain is reviewed. Twenty four published articles were eligible for inclusion in this systematic review in which a range of treatment regimens were evaluated including both B12 monotherapy and B12 in combination with other vitamins or conventional treatments, such as gabapentinoids. Overall, this systematic review demonstrates that there is currently some evidence for the therapeutic effect of B12 in the treatment of post-herpetic neuralgia (level II evidence) and the treatment of painful peripheral neuropathy (level III evidence).

Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management

Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potential mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.

Current Evidence for Diagnosis of Common Conditions Causing Low Back Pain: Systematic Review and Standardized Terminology Recommendations

OBJECTIVE

The purpose of this systematic review is to evaluate and summarize current evidence for diagnosis of common conditions causing low back pain and to propose standardized terminology use.

METHODS

A systematic review of the scientific literature was conducted from inception through December 2018. Electronic databases searched included PubMed, MEDLINE, CINAHL, Cochrane, and Index to Chiropractic Literature. Methodological quality was assessed with the Scottish Intercollegiate Guidelines Network checklists.

RESULTS

Of the 3995 articles screened, 36 (8 systematic reviews and 28 individual studies) met final eligibility criteria. Diagnostic criteria for identifying likely discogenic, sacroiliac joint, and zygapophyseal (facet) joint pain are supported by clinical studies using injection-confirmed tissue provocation or anesthetic procedures. Diagnostic criteria for myofascial pain, sensitization (central and peripheral), and radicular pain are supported by expert consensus-level evidence. Criteria for radiculopathy and neurogenic claudication are supported by studies using combined expert-level consensus and imaging findings.

CONCLUSION

The absence of high-quality, objective, gold-standard diagnostic methods limits the accuracy of current evidence-based criteria and results in few high-quality studies with a low risk of bias in patient selection and reference standard diagnosis. These limitations suggest practitioners should use evidence-based criteria to inform working diagnoses rather than definitive diagnoses for low back pain. To avoid the unnecessary complexity and confusion created by multiple overlapping and nonspecific terms, adopting International Association for the Study of Pain terminology and definitions is recommended.

Where do patients with MRI-confirmed single-level radiculopathy experience pain, and what is the clinical interpretability of these pain patterns? A cross-sectional diagnostic accuracy study

Background

Clinicians nominate the distribution of leg pain as being important in diagnosing nerve root involvement. This study aimed to identify: (i) common unisegmental radicular pain patterns and whether they were dermatomal, and (ii) whether these radicular pain patterns assisted clinician discrimination of the nerve root level involved.

Methods

A cross-sectional diagnostic accuracy study of adult patients with radicular leg pain at a hospital in Denmark. All patients had positive neurological signs (average 2.8 signs - hypoalgesia, diminished reflexes, muscle weakness, positive Straight Leg Raise test).Part 1 (pain patterns) was a secondary analysis of baseline pain pattern data collected during a clinical trial. The pain charts of 93 patients with an MRI and clinically confirmed single-level disc herniation with nerve root compression were digitised and layered to form a composite picture of the radicular patterns for the L5 and S1 nerve roots, which were then compared to published dermatomes.In Part 2 (clinical utility) we prospectively measured the discriminative ability of the identified pain patterns. The accuracy was calculated of three groups of six clinicians at classifying the nerve root affected in a randomized sequence of 53 patients, when not shown, briefly shown or continuously shown the composite pain patterns. In each group were two chiropractors, two medical doctors and two physiotherapists.

Results

There was a wide overlap in pain patterns from compromised L5 and S1 nerve roots but some distinguishing features. These pain patterns had approximately 50 to 80% overlap with published dermatomes. Clinicians were unable to determine with any accuracy above chance whether an individual pain drawing was from a person with a compromised L5 or S1 nerve root, and use of the composite pain drawings did not improve that accuracy.

Conclusions

While pain distribution may be an indication of radiculopathy, pain patterns from L5 or S1 nerve root compression only approximated those of sensory dermatomes, and level-specific knowledge about radicular pain patterns did not assist clinicians' diagnostic accuracy of the nerve root impinged. These results indicate that, on their own, pain patterns provide very limited additional diagnostic information about which individual nerve root is affected.

Observed patterns of cervical radiculopathy: how often do they differ from a standard, "Netter diagram" distribution?

BACKGROUND CONTEXT

Traditionally, cervical radiculopathy is thought to present with symptoms and signs in a standard, textbook, reproducible pattern as seen in a "Netter diagram." To date, no study has directly examined cervical radicular patterns attributable to single level pathology in patients undergoing ACDF.

PURPOSE

The purpose of this study is to examine cervical radiculopathy patterns in a surgical population and determine how often patients present with the standard textbook (ie, Netter diagram) versus nonstandard patterns.

STUDY DESIGN/SETTING

A retrospective study.

PATIENT SAMPLE

Patients who had single-level radiculopathy with at least 75% improvement of preoperative symptoms following ACDF were included.

OUTCOME MEASURES

Epidemiologic variables were collected including age, sex, weight, body mass index, laterality of symptoms, duration of symptoms prior to operative intervention, and the presence of diabetes mellitus. The observed pattern of radiculopathy at presentation, including associated neck, shoulder, upper arm, forearm, and hand pain and/or numbness, was determined from chart review and patient-derived pain diagrams.

METHODS

We identified all patients with single level cervical radiculopathy operated on between March 2011 and March 2016 by six surgeons. The observed pattern of radiculopathy was compared to a standard textbook pattern of radiculopathy that strictly adheres to a dermatomal map Fisher exact test was used to analyze categorical data and Student t test was used for continuous variables. A one-way ANOVA was used to determine differences in the observed versus expected radicular pattern. A logistic regression model assessed the effect of demographic variables on presentation with a nonstandard radicular pattern.

RESULTS

Overall, 239 cervical levels were identified. The observed pattern of pain and numbness followed the standard pattern in only 54% (129 of 239; p=.35). When a nonstandard radicular pattern was present, it differed by 1.68 dermatomal levels from the standard (p<.0001). Neck pain on the radiculopathy side was the most prevalent symptom; it was found in 81% (193 of 239) of patients and did not differ by cervical level (p=.72). In a logistic regression model, none of the demographic variables of interest were found to significantly impact the likelihood of presenting with a nonstandard radicular pattern.

CONCLUSIONS

Observed patterns of cervical radiculopathy only followed the standard pattern in 54% of patients and did not differ by the cervical level involved. Cervical radiculopathy often presents with a nonstandard pattern. Surgeons should think broadly when identifying causative levels because they frequently may not adhere to textbook descriptions in actual clinical practice. We observed III level of evidence.

Utility of Oblique Sagittal Reformatted and Three-dimensional Surface Reconstruction Computed Tomography in Foraminal Stenosis Decompression

Determining the responsible level of cervical radiculopathy can be difficult. Because asymptomatic findings are common in cervical radiculopathy, diagnoses based on imaging studies can be inaccurate. Therefore, we investigated whether the application of oblique sagittal reformatted computed tomography (oblique sagittal CT) and three-dimensional surface reconstruction CT (3DCT) affects surgical plans for patients with cervical foraminal stenosis and whether it assists diagnosis of foraminal stenosis. Accordingly, four reviewers, with office notes, observed the CT and magnetic resonance imaging (MRI) images of 18 patients undergoing surgical treatment for cervical radiculopathy. After reviewing the MRI and sagittal, coronal, and axial CT images, the reviewers recorded the operation to be performed; they examined oblique sagittal CT and 3DCT images of the same patients and noted any differences from their surgical plans. Consequently, we analyzed these changes in the decompressed foramina in the surgical plan; mean percent change in the plan was 18.1%. Inter-rater reliability improved from κ - 0.194 to κ - 0.240. Therefore, the addition of oblique and 3DCT images improves inter-rater reliability owing to changes in a part of decompressed foramina. The addition of oblique sagittal CT and 3DCT is helpful in evaluating the foramen and planning surgical treatment of cervical radiculopathy.

Current challenges in diagnosis of lumbar radiculopathy

Lumbar radiculopathy (LR) is a term used to describe a pain syndrome caused by compression or irritation of nerve roots in the lower back. The surgery cost for LR increased by 23% annually during 1992-2003 in the developed country. Although it is one of most common complaints in clinical practice, the diagnosis for LR is still very challenging. Here we discuss the current tools of LR diagnosis and highlight the needs to develop new diagnosis tools for LR.

Lumbar Disc Herniation, the Association Between Quantitative Sensorial Test and Magnetic Resonance Imaging Findings

OBJECTIVE

Quantitative sensorial tests (QST) are used for evaluating specific sensorial nerve function. In this study, QST and magnetic resonance imaging (MRI) findings are compared in lumbar disc herniation patients, and the accuracy of QST data was investigated.

MATERIAL AND METHODS

Sixty-four patients between 18 and 70 years of age suffering from radicular pain with positive Lasegue's test were included in this study. Specific criteria included complaints due to L5 discopathy. MRI findings were classified according to the Pfirmann grading system, and QST was applied to the L5 dermatoma of both symptomatic and nonsymptomatic legs of all patients. Vibration detection threshold, heat detection threshold, cold detection threshold, and heat pain detection threshold values were obtained, and MRI findings were classified according to the Pfirmann grading system.

RESULTS

When we compared the symptomatic and nonsymptomatic legs of participants, there were significant differences by means of all QST parameters (0 = 0.00). In a comparison of the QST and MRI Pfirmann grading systems, there is also a strong parallel statistical correlation between the Pfirmann grade and QST parameters (P < 0.05).

CONCLUSIONS

According to the results of our study, QST has an additive effect to MRI for nerve root compression evaluation in the clinical basis, which might enable more sensitive diagnosis and treatment protocol. QST can also be an alternative method for evaluation of nerve root compression in patients who have contraindications for MRI.

Therapeutic Effect of Medical Ozone on Lumbar Disc Herniation

BACKGROUND This study aimed to investigate the therapeutic effect of low, medium, and high concentrations of medical ozone on trauma-induced lumbar disc herniation. MATERIAL AND METHODS A total of 80 patients were included and were grouped into a control group, a low medical ozone (20 μg/ml) group, a medium medical ozone (40 μg/ml) group, and a high medical ozone (60 μg/ml) group. The CT scan and enzyme-linked immunosorbent assay (ELISA) were used to detect IL-6 level, SOD activity, IgM, and IgG levels upon admission and at 6 and 12 months after follow-up. The area under the ROC curve (AUC) was calculated for visual analogue scale (VAS) and efficiency rate. RESULTS All patients showed disc retraction at 6- and 12-month follow-up; while patients in the medium medical ozone (40 μg/ml) group showed the greatest disc retraction rate. The IL-6, IgM, IgG, and VAS levels significantly decreased while SOD activity increased among all groups over time (p<0.05). The AUCIL-6, AUCIgG, AUCIgM, and AUCSOD was closest to 1 in the medium medical ozone (40 μg/ml) group compared with other groups (p<0.01), with the highest efficacy at 6 (35%) and 12 (85%) months during follow-up. CONCLUSIONS Low concentrations of medical ozone (20 μg/ml and 40 μg/ml) reduced the serum IL-6, IgG, and IgM expression, presenting as analgesic and anti-inflammatory effects, while high concentrations of medical ozone (60 μg/ml) increased the serum IL-6, IgG, IgM expression, presenting as pain and pro-inflammatory effects. The medical ozone concentration of 40 μg/ml showed the optimal treatment efficacy.

Entrapment Neuropathies: Challenging Common Beliefs With Novel Evidence

Entrapment neuropathies are the most prevalent type of peripheral neuropathy and often a challenge to diagnose and treat. To a large extent, our current knowledge is based on empirical concepts and early (often biomechanical) studies. This Viewpoint will challenge some of the current beliefs with recent advances in both basic and clinical neurosciences. J Orthop Sports Phys Ther 2018;48(2):58-62. doi:10.2519/jospt.2018.0603.

Comparison of Symptoms From C6 and C7 Radiculopathy

STUDY DESIGN

Case series.

OBJECTIVE

This study compared the locations of arm pain, sensory symptoms, and subjective complaints of arm weakness in patients with cervical radiculopathy from MRI confirmed C6 and C7 nerve root compression.

SUMMARY OF BACKGROUND DATA

Cervical radiculopathy is defined as arm pain, sensory and motor symptoms caused by irritation of a cervical nerve root. The C6 and C7 roots are most commonly involved, and differentiating symptoms associated with each root has proven difficult. Cervical MRI allows accurate identification of nerve root compression and therefore makes it possible to explore symptom patterns that may differentiate C6 from C7 radiculopathy.

METHODS

A total of 122 patients with symptoms suggestive of cervical radiculopathy were recruited. Of these, 30 patients had MRI confirmed C6 and 39 patients C7 nerve root compression. By completing a study questionnaire, patients reported specific arm weakness, and marked the location of arm pain and tingling/numbness on graphic representations of the arm. Marked areas were interpreted by superimposing a grid that divided the arm into 54 distinct areas. The frequencies of reported symptoms with C6 and C7 were totaled and then compared with likelihood rations. Power analysis calculated that 27 patients would be needed in each group based on the assumption that a 30 percentage point difference in frequency of specific symptom would be clinically useful for differentiating C6 from C7 radiculopathy.

RESULTS

Arm pain and sensory symptoms were diffuse, and were not distinctly different for C6 or C7 radiculopathy. Some weakness was reported by 41 percent of patients, with specific descriptions of weakness having limited value for differentiating between radiculopathies.

CONCLUSION

The location of pain and sensory symptoms, and specific weakness complaints associated with symptomatic C6 and C7 nerve root compression overlap to the extent that caution should be exercised when predicting root involvement based on symptoms.

LEVEL OF EVIDENCE

3.

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

BACKGROUND CONTEXT

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

PURPOSE

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

STUDY DESIGN

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

PATIENT SAMPLE

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

OUTCOME MEASURES

The outcome measures were items from history and physical examination.

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Relevant Anatomy, Morphology, and Implantation Techniques of the Dorsal Root Ganglia at the Lumbar Levels

OBJECTIVES

While dorsal root ganglion (DRG) stimulation has been available in Europe and Australia for the past five years and in the United States for the past year, there are no published details concerning the optimal procedures for DRG lead implantation.

MATERIALS AND METHODS

We describe several techniques that can be applied to implant cylindrical leads over the DRG, highlighting some tips and tricks according to our experiences. Focus is mainly shifted toward implantations in the lumbar area. We furthermore give some insights in the results we experienced in Spain as well as some worldwide numbers.

IMPLANT TECHNIQUES AND RESULTS

A 14-gauge needle is placed using a "2-Level Technique (2-LT)" or exceptionally a "1-Level Technique (1-LT)" or a "Primary- or Secondary Technique" at the level of L5. The delivery sheath, loaded with the lead, is advanced toward the targeted neural foramen. The lead is placed over the dorsal aspect of the DRG. A strain relief loop is created in the epidural space. Sheath and needle are retracted and the lead is secured using an anchor or anchorless technique. In Spain, 87.2% (N = 78) of the selected patients have been successfully implanted. Seven (8.9%) had a negative trial and three (4.2%) were explanted. Average VAS score decreased from 8.8 to 3.3 and on average 94.5% of the pain area was covered. In our center's subjects (N = 47 patients, 60.3% of all implanted patients in Spain), VAS scores decreased from an average of 8.8-1.7 and pain coverage averaged 96.4%. We used an average of 1.8 electrodes. Worldwide more than 4000 permanent cases have been successfully performed.

CONCLUSIONS

We present implantation techniques whereby a percutaneous lead is placed over the DRG through the use of a special designed delivery sheath. Further investigation of the safety, efficacy, and sustainability of clinical outcomes using these devices is warranted.

The diagnostic accuracy and test-retest reliability of the Dutch PainDETECT and the DN4 screening tools for neuropathic pain in patients with suspected cervical or lumbar radiculopathy

BACKGROUND

It is important to identify neuropathic pain early to guide treatment decisions and prevent chronicity. There is lack of evidence whether the Dutch painDETECT questionnaire and Douleure Neuropathique en 4 questions (DN4) can adequately assess neuropathic pain.

METHODS

Patients suspected of cervical or lumbar radiculopathy were eligible for inclusion. The Dutch painDETECT and DN4 were considered as the index tests and were compared to the reference test consisting of the consensus expert diagnosis by using the grading system for neuropathic pain. The index tests and neuropathic pain diagnosis were blindly performed. Diagnostic accuracy was determined by calculating sensitivity, specificity, predictive values and likely hood ratios. Test-retest reliability for the index tests was assessed using Intraclass Correlation Coefficients (ICC).

RESULTS

A total of 180 patients were included, of which 110 for the reliability analysis. Fifty-nine patients (33%) had neuropathic pain according to the reference test. Both the painDETECT and DN4 had moderate sensitivity of respectively 75% (95% CI: 61.6-85.0) and 76% (95% CI: 63.4-86.4) and poor specificity of respectively 51% (95% CI: 42.0-60.4) and 42% (95% CI: 33.2-51.5). Combining negative test results for both screening tools increased the sensitivity up to 83% (95% CI: 71.0-91.6). The ICC for the painDETECT was 0.91 (95% CI: 0.86-0.94) and for the DN4 0.86 (95% CI: 0.80-0.91).

CONCLUSIONS

The use of the Dutch painDETECT and the DN4 in patients with suspected radiculopathy should not be recommended yet. A combination of both screening tools seems most suitable to rule out neuropathic pain in patients suspected of radiculopathy.

LEVEL OF EVIDENCE

Diagnosis, Level 1B.

A model for radiating leg pain of endometriosis

Endometriosis is a prevalent female health disorder that often leads to back pain and radiating leg pain. Patients with such pain often seek care from multiple health care professionals, including manual therapists. We hypothesized that endometrioma can induce nerve inflammation thus the radiating leg pain that often accompanies endometriosis. To model sciatic endometriosis in female Wistar rats, a section of uterine horn was autotransplanted to the sciatic nerve. Uterus sections with the endometrium removed and autotransplanted to the sciatic nerve served as controls. After 1, 3, and 15 months the nerves were harvested and processed for immune cell presence and for neural elements. Control nerves were harvested after 4 months. All autotransplants survived, resulting in a fusion of the uterus sections to the nerves. Macroscopically, turgid cysts apposed to the nerves characterized the complexes. Microscopically, the complexes contained recruited macrophages, indicating persistent inflammation, and were innervated by small diameter axons. Only 1 of 8 control rats developed a small cyst, presumably due to residual endometrium. The persistent immune response and innervation suggest the nerve-uterus complexes as sources of inflammation and persistent neural discharge, and thus pain. This model could shed light upon the radiating leg pain that often accompanies endometriosis. Manual therapists should be aware of the possibility of endometriosis causing symptoms and examination findings that mimic musculoskeletal etiologies.

Cervicobrachial pain - How Often is it Neurogenic?

INTRODUCTION

Neck pain associated with pain in the arm (cervicobrachial pain) is a common complaint in patients seeking physiotherapy management. The source of symptoms for this complaint is commonly presumed to be neural. However, this pain pattern could also result from various other innervated tissue structures of the upper quarter. Knowledge about frequency of neural structures being a predominant source of symptoms would help in implementing appropriate therapeutic strategies such as neural tissue mobilization along with other complimentary therapies for optimal outcomes.

AIM

To determine the frequency of cervicobrachial pain being neurogenic.

MATERIALS AND METHODS

Participants (n=361) aged between 20-65 years, reporting cervicobrachial pain were screened for neurogenic nature of symptoms. These physical signs included: active and passive movement dysfunction, adverse responses to neural tissue provocation tests, tenderness on palpating nerve trunks and related cutaneous tissues and evidence of a related local area of pathology (Clinical/radiological). The consistency of all these signs was checked to identify a significant neural involvement.

RESULTS

Descriptive statistics were used to analyse data. Of 361 participants, 206 were males (44.6 ±10.8 years) and 155 were females (41.8 ± 11.2 years). The frequency of neurogenic cervicobrachial pain was determined to be 19.9% (n=72) and the non-neurogenic sources for symptoms were attributed to 80.1% (n=289) of screened participants.

CONCLUSION

Lower frequency of cervicobrachial pain being neurogenic indicates thorough screening for appropriate therapeutic interventions to be successful.

Predictive Factors for Successful Outcome of Pulsed Radiofrequency Treatment in Patients with Intractable Lumbosacral Radicular Pain

BACKGROUND

In a previous prospective study on pulsed radiofrequency (PRF) treatment adjacent to the lumbar dorsal root ganglion (DRG) for patients with chronic lumbosacral radicular pain, we reported success in 55.4% of the patients at 6 months. Identification of predictors for success after PRF may improve outcome. We assessed the predictors of PRF in patients with chronic intractable lumbosacral radicular pain.

METHODS

Patients with monosegmental chronic lumbosacral radicular pain of L5 or S1 first received a selective nerve root block at the corresponding level. Independent of the result of this block a PRF treatment at the same level was performed. At 6 weeks, 3 months, and 6 months after the procedure the outcome was evaluated.

RESULTS

A positive diagnostic nerve root block and age ≥ 55 were predictive factors for successful outcome at 6 months, while disability was a negative predictor.The use of failed back surgery syndrome, gender, duration of pain, Numerical Rating Scale, level and side of treatment, DN4, and RAND-36 as predictors for success was not supported.

CONCLUSIONS

Successful outcome after PRF adjacent to the DRG, in patients with intractable chronic lumbosacral radicular pain, is more likely in patients ≥ 55 years, with limited disability and after a positive diagnostic nerve root block. A combination of all these factors creates a fair predictive value (AUC: 0.73).

Pulsed radiofrequency for chronic intractable lumbosacral radicular pain: a six-month cohort study

BACKGROUND AND OBJECTIVES

There is little evidence concerning the medical management of lumbosacral radicular pain. The prognosis for patients suffering pain for more than 3 months is poor. Pulsed radiofrequency (PRF) treatment of the dorsal root ganglion (DRG) has been suggested as a minimally invasive treatment. We studied the effect on pain and quality of life of PRF treatment of the DRG in patients with chronic, severe lumbosacral radicular pain.

METHODS

Patients with lumbosacral radicular pain were screened to select a homogeneous population. PRF treatment of the DRG was performed at L5 or S1. Evaluation was carried out at 6 weeks, 3 months, and 6 months. Pain reduction and "fully recovered" or "much improvement," in terms of the global perceived effect, were the primary outcomes. Quality of life (RAND-36), disability (Oswestry Disability Index), and the neuropathic pain scales leeds assessment of neuropathic symptoms and signs (LANSS) and DN4 were registered at each time point. Medication use was scored with the Medication Quantification Scale.

RESULTS

Out of 461 screened patients, 65 were included. According to the intention to treat analysis, clinical success was achieved in 56.9%, 52.3%, and 55.4% of the patients at respectively 6 weeks, 3 months, and 6 months. DN4, Oswestry Disability Index and physical component for the RAND-36 quality of life improved significantly while the mental component remained unchanged. The number of patients on opioids was reduced.

CONCLUSIONS

PRF treatment of the DRG may be considered for patients with chronic, severe lumbosacral radicular pain refractory to conventional medical management.

The hip-spine connection: understanding its importance in the treatment of hip pathology

EDUCATIONAL OBJECTIVES As a result of reading this article, physicians should be able to: 1. Discuss the kinematic relationship between the hip and lumbar spine. 2. Explain the innervation of the hip and lumbar spine and how they relate to one another. 3. Recognize the effect of hip disease on the lumbar spine in an athletic population, prior to the onset of degenerative changes. 4. Describe an algorithm for diagnosis and treatment of patients who present with concomitant hip and lumbar spine pain. The hip and lumbar spine are closely related and can create similar patterns of pain and dysfunction. Diagnosis and treatment of hip and spine-related conditions can be challenging due to symptom overlap. Successful evaluation and treatment of hip and lumbar spine conditions requires a thorough understanding the hip-spine connection. Historically the hip-spine connection has been considered in the context of arthrosis; however, the hip-spine connection also needs to be considered in a younger athletic population. The purpose of this review is to describe the hip-spine connection, discuss the clinical implications of this connection, and offer an approach to diagnosis and treatment.

Sciatica: detection and confirmation by new method

We need to overcome limitations of present assessment and also integrate newer research in our work about sciatica. Inflammation induces changes in the DRG and nerve root. It sensitizes the axons. Nociceptor is a unique axon. It is pseudo unipolar: both its ends, central and peripheral, behave in similar fashion. The nerve in periphery which carries these axons may selectively become sensitive to mechanical pressure--"mechanosensitized," as we coin the phrase. Many pain questionnaires are used and are effective in identifying neuropathic pain solely on basis of descriptors but they do not directly physically correlate nerve root and pain. A thorough neurological evaluation is always needed. Physical examination is not direct pain assessment but testing mobility of nerve root and its effect on pain generation. There is a dogmatic dominance of dermatomes in assessment of leg pain. They are unreliable. Images may not correlate with symptoms and pathology in about 28% of cases. Electrophysiology may be normal in purely inflamed nerve root. Palpation may help in such inflammatory setting to refine our assessment further. Confirmation of sciatica is done by selective nerve root block (SNRB) today but it is fraught with several complications and needs elaborate inpatient and operating room set up. We have used the unique property of the pseudo unipolar axon that both its ends have similar functional properties and so inject along its peripheral end sodium channel blockers to block the basic cause of the mechanosensitization namely upregulated sodium channels in the root or DRG. Thus using palpation we may be able to detect symptomatic nerve in stage of inflammation and with distal end injection, along same inflamed nerve we may be able to abolish and so confirm sciatica. Discussions of sciatica pain diagnosis tend to immediately shift and centre on the affected disc rather than the nerve. Theoretically it may be possible to detect the affected nerve by palpating the nerve and relieve pain moment we desensitize the nerve.

Lumbar radiculopathy and its neurobiological basis

Lumbar radiculopathy, a group of diseases in which the dorsal root ganglia (DRG) or dorsal roots are adversely affected by herniated discs or spinal stenosis, are clinically characterized by spontaneous and evoked types of pain. The pain is underpinned by various distinct pathophysiological mechanisms in the peripheral and central nervous systems. However, the diagnosis of lumbar radiculopathy is still unsatisfactory, because the association of the pain with the neurobiological basis of radiculopathy is largely unknown. Several animal models used to explore the underlying neurobiological basis of lumbar radiculopathy could be classified as mechanical, chemical, or both based on the component of injury. Mechanical injury elevates the intraneural pressure, reduces blood flow, and eventually establishes ischemia in the dorsal root and the DRG. Ischemia may induce ischemic pain and cause nerve damage or death, and the subsequent nerve damage or death may induce neuropathic pain. Chemical injury predominately induces inflammation surrounding the dorsal roots or DRG and consequent inflammatory mediators cause inflammatory pain. Furthermore, DRG neurons sensitized by inflammatory mediators are hypersensitive to innocuous mechanical force (stretch or compression) and responsible for mechanical allodynia in radiculopathy. As well, central sensitization in the spinal cord may play an important role in pain generation in lumbar radiculopathy. Increasing knowledge of pain-generating mechanisms and their translation into clinical symptoms and signs might allow for dissecting the mechanisms that operate in each patient. With precise clinical phenotypic characterization of lumbar radiculopathy and its connection to a specific underlying mechanism, we should be able to design optimal treatments for individuals. This review discusses the present knowledge of lumbar radiculopathy and proposes a novel mechanism-based classification.

Establishing the diagnosis of low back pain: patient selection for interventional pain medicine

SUMMARY Low back pain is one of the most prominent healthcare problems but there is no gold standard for its diagnosis. Aspecific low back pain can be subdivided into radicular and mechanical pain. The diagnosis mainly relies on a combination of elements, such as medical history, physical examination, medical imaging and other possible additional tests. Once a working diagnosis has been established, confirmation of the causative structure and level is sought by means of diagnostic blocks. The use of the different diagnostic tests and blocks should be guided by the balance between the potential benefit (mainly in terms of improved treatment outcome, the possible burden for the patient and the chances of withholding potential effective treatment to patients) with false-negative test results.