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Su CY, Huang GS, Chang WC, Wang CC, Chen CW, Hsu YC. The Value of 18F-FDG PET/MRI in Detecting Lumbar Radiculopathy for Selective Percutaneous Endoscopic Discectomy: a Case Report. Nucl Med Mol Imaging 2023; 57:247-250. [PMID: 37720881 PMCID: PMC10504134 DOI: 10.1007/s13139-023-00797-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/09/2023] [Accepted: 03/16/2023] [Indexed: 03/31/2023] Open
Abstract
Magnetic resonance imaging (MRI) is the most popular imaging modality for investigating intervertebral disc herniation. However, it has a high chance for identifying incidental findings that are morphologically or structurally abnormal but not responsible for patients' symptoms. Although a previous study suggested that 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/magnetic resonance imaging (PET/MRI) may help identify neuroinflammation in lumbar radiculopathy, there is currently no direct evidence obtained from surgery. Here, we describe the case of a 32-year-old man with low back pain and right leg paresthesia for 7 months. MRI demonstrated disc herniation at the L3-L4, L4-L5 and L5-S1 levels, causing bilateral L5 and left S1 root compression. 18F-FDG PET/MRI demonstrated increased 18F-FDG uptake at the right L5 root, which was compatible with the patient's symptoms. Transforaminal percutaneous endoscopic lumbar discectomy (PELD) was performed. Intraoperative images revealed a swollen nerve root at the right L5 after removal of the herniated disc. After surgery, the patient experienced immediate pain relief and had no recurrence at the 6-month follow-up. When performing PELD in patients with multilevel radiculopathy identified on MRI, the use of 18F-FDG PET/MRI can help in accurate localization of the symptomatic roots and minimize surgical incision and soft-tissue injury.
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Affiliation(s)
- Chih-Ying Su
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Cheng-kung Rd., Neihu Dist, 114 Taipei, Taiwan, Republic of China
- Department of Radiology, Taichung Armed Forces General Hospital, Taichung, Taiwan, Republic of China
| | - Guo-Shu Huang
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Cheng-kung Rd., Neihu Dist, 114 Taipei, Taiwan, Republic of China
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Wei-Chou Chang
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Cheng-kung Rd., Neihu Dist, 114 Taipei, Taiwan, Republic of China
| | - Chih-Chien Wang
- Department of Orthopedic, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chun-Wen Chen
- Department of Radiology, Taichung Armed Forces General Hospital, Taichung, Taiwan, Republic of China
- Department of Medical Imaging and Radiological Sciences, Central Taiwan University of Science and Technology, Taichung City, Taiwan, Republic of China
- Department of Radiology, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Yi-Chih Hsu
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Cheng-kung Rd., Neihu Dist, 114 Taipei, Taiwan, Republic of China
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Schmid AB, Tampin B, Baron R, Finnerup NB, Hansson P, Hietaharju A, Konstantinou K, Lin CWC, Markman J, Price C, Smith BH, Slater H. Recommendations for terminology and the identification of neuropathic pain in people with spine-related leg pain. Outcomes from the NeuPSIG working group. Pain 2023; 164:1693-1704. [PMID: 37235637 PMCID: PMC10348639 DOI: 10.1097/j.pain.0000000000002919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 02/16/2023] [Accepted: 02/24/2023] [Indexed: 05/28/2023]
Abstract
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.
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Affiliation(s)
- Annina B. Schmid
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Brigitte Tampin
- Department of Physiotherapy, Sir Charles Gairdner Hospital, Perth, Australia
- Curtin School of Allied Health, Faculty of Health Sciences, Curtin University, Perth, Australia
- Faculty of Business and Social Sciences, Hochschule Osnabrueck, University of Applied Sciences, Osnabrueck, Germany
| | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Nanna B. Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Per Hansson
- Department of Pain Management & Research, Norwegian National Advisory Unit on Neuropathic Pain, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Aki Hietaharju
- Department of Neurology, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Kika Konstantinou
- School of Medicine, Keele University, Keele, Staffordshire, United Kingdom
- Haywood Hospital, Midlands Partnership Foundation NHS Trust, Staffordshire, United Kingdom
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- Sydney Musculoskeletal Health, the University of Sydney, Sydney Australia
| | - John Markman
- Translational Pain Research Program, Departments of Neurosurgery and Neurology, University of Rochester, Rochester, NY, United States
| | - Christine Price
- Patient Advocate Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Blair H. Smith
- Division of Population Health and Genomics, University of Dundee, Dundee, Scotland
| | - Helen Slater
- Curtin School of Allied Health, Faculty of Health Sciences, Curtin University, Perth, Australia
- Division of Population Health and Genomics, University of Dundee, Dundee, Scotland
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3
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Schmid AB, Dove L, Ridgway L, Price C. Early surgery for sciatica. BMJ 2023; 381:791. [PMID: 37076178 PMCID: PMC10113959 DOI: 10.1136/bmj.p791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Affiliation(s)
- Annina B Schmid
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK
| | - Lucy Dove
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK
| | - Lucy Ridgway
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK
| | - Christine Price
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, UK
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4
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Skorupska E, Dybek T, Rychlik M, Jokiel M, Zawadziński J, Dobrakowski P. Amplified Vasodilatation within the Referred Pain Zone of Trigger Points Is Characteristic of Gluteal Syndrome-A Type of Nociplastic Pain Mimicking Sciatica. J Clin Med 2021; 10:jcm10215146. [PMID: 34768666 PMCID: PMC8584656 DOI: 10.3390/jcm10215146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/20/2021] [Accepted: 10/26/2021] [Indexed: 11/16/2022] Open
Abstract
Gluteal syndrome (GS) mimicking sciatica is a new disease that has been recently recognized and included in the International Classification of Diseases, 11th Revision. The present study examines nociplastic pain involvement in GS and sciatica patients using a new Skorupska protocol (SP) test that provokes amplified vasodilatation in the area of expected muscle-referred pain. A positive test is confirmed if there is (i) a development of autonomic referred pain (AURP) and (ii) an increase in the delta of average temperature (Δ₸°) > 0.3 °C at the end of the stimulation and during the observation SP phases. Chronic GS (n = 20) and sciatica (n = 30) patients were examined. The SP test confirmed muscle-referred pain for (i) all GS patients with 90.6% positive thermograms (Δ₸° 0.6 ± 0.8 °C; maximum AURP 8.9 ± 13.6% (both p < 0.05)) and (ii) those sciatica (n = 8) patients who reported pain sensation during the test with 20.6% positive thermograms (Δ₸° 0.7 ± 0.7 °C; maximum AURP 15.1 ± 17.8% (both p < 0.05)). The remaining sciatica (n = 22) patients did not report pain during the test and presented a Δ₸° decrease and the AURP size below 1%. Conclusion: Amplified vasodilatation suggesting nociplastic pain involvement was confirmed for all GS and sciatica patients who reported painful sensations in the zone typical for gluteus minimus referred pain during the test.
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Affiliation(s)
- Elzbieta Skorupska
- Department of Physiotherapy, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (M.J.); (J.Z.)
- Faculty of Physical Education and Physiotherapy, Opole University of Technology, 45-758 Opole, Poland;
- Correspondence:
| | - Tomasz Dybek
- Faculty of Physical Education and Physiotherapy, Opole University of Technology, 45-758 Opole, Poland;
| | - Michał Rychlik
- Department of Virtual Engineering, Poznan University of Technology, 60-965 Poznan, Poland;
| | - Marta Jokiel
- Department of Physiotherapy, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (M.J.); (J.Z.)
- Department of Traumatology, Orthopedics and Hand Surgery, Poznan University of Medical Sciences, 60-761 Poznan, Poland
| | - Jarosław Zawadziński
- Department of Physiotherapy, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (M.J.); (J.Z.)
| | - Paweł Dobrakowski
- Psychology Institute, Humanitas University in Sosnowiec, 41-200 Sosnowiec, Poland;
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Schmid AB, Fundaun J, Tampin B. [Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management : German version]. Schmerz 2021; 35:419-433. [PMID: 34505948 DOI: 10.1007/s00482-021-00584-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Annina B Schmid
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford University, West Wing Level 6, OX3 9DU, Oxford, Großbritannien.
| | - Joel Fundaun
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford University, West Wing Level 6, OX3 9DU, Oxford, Großbritannien.,High Country Physical Therapy, Laramie, WY, USA
| | - Brigitte Tampin
- Department of Physiotherapy, Sir Charles Gairdner Hospital, Perth, Westaustralien, Australien.,School of Physiotherapy and Exercise Science, Curtin University, Westaustralien, Australien.,Fakultät Wirtschafts- und Sozialwissenschaften, Hochschule Osnabrück, Osnabrück, Deutschland
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6
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Verheijen EJA, Bonke CA, Amorij EMJ, Vleggeert-Lankamp CLA. Epidural steroid compared to placebo injection in sciatica: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3255-3264. [PMID: 33974132 DOI: 10.1007/s00586-021-06854-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/18/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE The purpose of this systematic review and meta-analysis was to determine whether epidural steroid injections (ESI) are superior to epidural or non-epidural placebo injections in sciatica patients. METHODS The PubMed, Embase, Cochrane Library, and Web of science databases were searched for trials comparing ESI to epidural or non-epidural placebo. Risk of bias was assessed using the Cochrane RoB 2 tool. The primary outcome measures were pooled using a random-effects model for 6-week, 3-month, and 6-month follow-up. Secondary outcomes were described qualitatively. Quality of evidence was graded using GRADE classification. RESULTS Seventeen out of 732 articles were included. ESI was superior compared to epidural placebo at 6 weeks (- 8.6 [- 13.4; - 3.9]) and 3 months (- 5.2 [- 10.1; - 0.2]) for leg pain and at 6 weeks for functional status (- 4.1 [- 6.5; - 1.6]), though the minimally clinical important difference (MCID) was not met. There was no difference in ESI and placebo for back pain, except for non-epidural placebo at 3 months (6.9 [1.3; 12.5]). Proportions of treatment success were not different. ESI reduced analgesic intake in some studies and complication rates are low. CONCLUSION The literature indicates that ESI induces larger improvements in pain and disability on the short term compared to epidural placebo, though evidence is of low to moderate quality and MCID is not met. Strong conclusions for longer follow-up or for comparisons with non-epidural placebo cannot be drawn due to general low quality of evidence and limited number of studies. Epidural injections can be considered a safe therapy.
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Affiliation(s)
- E J A Verheijen
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands. .,Department of Neurosurgery, Spaarne Gasthuis Hospital, Haarlem/Hoofddorp, The Netherlands.
| | - C A Bonke
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - E M J Amorij
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - C L A Vleggeert-Lankamp
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.,Department of Neurosurgery, Spaarne Gasthuis Hospital, Haarlem/Hoofddorp, The Netherlands
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7
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Luo CA, Lu ML, Kaliya-Perumal AK, Chen LH, Chen WJ, Niu CC. Degenerative cervical myelopathy presenting as subjective lower limb weakness could be a trap towards misdiagnosis. Sci Rep 2020; 10:21188. [PMID: 33273536 PMCID: PMC7712653 DOI: 10.1038/s41598-020-78139-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 11/09/2020] [Indexed: 11/17/2022] Open
Abstract
When patients presenting with subjective lower limb weakness (SLLW) are encountered, it is natural to suspect a lumbar pathology and proceed with related clinical examination, investigations and management. However, SLLW could be a sign of degenerative cervical myelopathy (DCM) due to an evolving cord compression. In such circumstances, if symptoms are not correlated to myelopathy at the earliest, there could be potential complications over time. In this study, we intend to analyse the outcomes after surgical management of the cervical or thoracic cord compression in patients with SLLW. Retrospectively, patients who presented to our center during the years 2010–2016 with sole complaint of bilateral SLLW but radiologically diagnosed to have a solitary cervical or thoracic stenosis, or tandem spinal stenosis and underwent surgical decompression procedures were selected. Their clinical presentation was categorised into three types, myelopathy was graded using Nurick’s grading and JOA scoring; in addition, their lower limb functional status was assessed using the lower extremity functional scale (LEFS). Functional recovery following surgery was assessed at 6 weeks, 3 months, 6 months, one year, and two years. Selected patients (n = 24; Age, 56.4 ± 10.1 years; range 32–78 years) had SLLW for a period of 6.4 ± 3.2 months (range 2–13 months). Their preoperative JOA score was 11.3 ± 1.8 (range 7–15), and LEFS was 34.4 ± 7.7 (range 20–46). Radiological evidence of a solitary cervical lesion and tandem spinal stenosis was found in 6 and 18 patients respectively. Patients gradually recovered after surgical decompression with LEFS 59.8 ± 2.7 (range 56–65) at 1 year and JOA score 13.6 ± 2.7 (range − 17 to 100) at 2 years. The recovery rate at final follow up was 47.5%. Our results indicate the importance of clinically suspecting SLLW as an early non-specific sign of DCM to avoid misdiagnosis, especially in patients without conventional upper motor neuron signs. In such cases, surgical management of the cord compression resulted in significant functional recovery and halted the progression towards permanent disability.
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Affiliation(s)
- Chi-An Luo
- Department of Orthopaedic Surgery, New Taipei Municipal TuCheng Hospital, New Taipei, 236, Taiwan, ROC.,Bone and Joint Research Center, Linkou Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan, ROC
| | - Meng-Ling Lu
- Bone and Joint Research Center, Linkou Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan, ROC.,Department of Orthopaedic Surgery, Spine Division, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, 833, Taiwan, ROC
| | - Arun-Kumar Kaliya-Perumal
- Bone and Joint Research Center, Linkou Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan, ROC.,Department of Orthopaedic Surgery, Spine Division, Chang Gung Memorial Hospital at Linkou, 5, Fuxing Street, Taoyuan, Guishan, 333, Taiwan, ROC.,Department of Orthopaedic Surgery, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur, Tamil Nadu, 603319, India
| | - Lih-Huei Chen
- Department of Orthopaedic Surgery, Spine Division, Chang Gung Memorial Hospital at Linkou, 5, Fuxing Street, Taoyuan, Guishan, 333, Taiwan, ROC
| | - Wen-Jer Chen
- Department of Orthopaedic Surgery, Chung Shan Hospital, Taipei, 106, Taiwan, ROC
| | - Chi-Chien Niu
- Bone and Joint Research Center, Linkou Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan, ROC. .,Department of Orthopaedic Surgery, Spine Division, Chang Gung Memorial Hospital at Linkou, 5, Fuxing Street, Taoyuan, Guishan, 333, Taiwan, ROC.
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Schmid AB, Fundaun J, Tampin B. Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management. Pain Rep 2020; 5:e829. [PMID: 32766466 PMCID: PMC7382548 DOI: 10.1097/pr9.0000000000000829] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 05/04/2020] [Accepted: 05/30/2020] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Annina B. Schmid
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, United Kingdom
| | - Joel Fundaun
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, United Kingdom
- High Country Physical Therapy, Laramie, WY, USA
| | - Brigitte Tampin
- Department of Physiotherapy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Physiotherapy and Exercise Science, Curtin University, Western Australia, Australia
- Faculty of Business Management and Social Sciences, Hochschule Osnabrück, University of Applied Sciences, Osnabrück, Germany
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Santa Barbara MT, Cortazzo M, Emerick T, Furnier J, Duff J, Shapiro S, Zigler CK, Badway A, Sowa G. Descriptive Analysis of an Interdisciplinary Musculoskeletal Program. PM R 2019; 12:639-646. [PMID: 31747134 DOI: 10.1002/pmrj.12288] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 11/04/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Interdisciplinary musculoskeletal programs address comorbidities confounding musculoskeletal conditions and serve as an alternative to the single provider model. OBJECTIVE Descriptive analysis of an interdisciplinary musculoskeletal program. DESIGN Retrospective descriptive analysis of patients enrolled in an interdisciplinary musculoskeletal program. Retrospective subanalysis: cohort of patients enrolled in interdisciplinary program with low back pain compared to historical cohort of patients in a single provider clinic. SETTING Academic interdisciplinary musculoskeletal health program. PATIENTS Patients referred to program with at least one follow-up visit over a 2-year period. INTERVENTIONS Interdisciplinary musculoskeletal program involving physiatry, pain anesthesia, nutrition, psychology, rheumatology, sleep medicine, nursing, and physical therapy. MAIN OUTCOME MEASUREMENTS Patient Specific Functional Scale (PSFS), Oswestry Low Back Disability Index (ODI), number of magnetic resonance imaging (MRI) scans, computed tomography (CT) scans, opioid prescriptions; Press Ganey scores. RESULTS One hundred and seventy-three patients were enrolled and had at least one follow-up visit. Twenty-four percent of patients with any musculoskeletal complaint demonstrated clinically significant improvements in total PSFS. Mean improvement in PSFS was + 0.864 (SD 1.94), which was a statistically significant improvement (P = .0005), but not clinically significant. Magnetic resonance imaging was ordered for 5% of patients, and no computed tomography scans were ordered. Six percent of patients received opioid prescriptions. Press Ganey scores: 96% responded favorably in regard to physician communication quality, 86% of patients responded favorably for access to care, and 78% responded favorably for care coordination. 27.8% of patients with low back pain in the interdisciplinary program achieved a significant decrease in their ODI, compared to 26.6% in the single provider clinic (P = .87). CONCLUSIONS Interdisciplinary musculoskeletal programs are a promising model to improve the functioning of patients with musculoskeletal pain and decrease downstream utilization. These programs may be more appropriate for patients at higher risk of developing chronic pain.
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Affiliation(s)
- Matthew T Santa Barbara
- Henry Ford Health System, West Bloomfield, MI.,Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Megan Cortazzo
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Trent Emerick
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jessica Furnier
- Health Services Division, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jesse Duff
- Health Services Division, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Steve Shapiro
- Health Services Division, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Christine K Zigler
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Andrea Badway
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, PA.,Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Gwendolyn Sowa
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, PA.,Ferguson Laboratory for Orthopaedic and Spine Research, UPMC Rehabilitation Institute, Pittsburgh, PA
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10
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Understanding sciatica: illness and treatment beliefs in a lumbar radicular pain population. A qualitative interview study. BJGP Open 2019; 3:bjgpopen19X101654. [PMID: 31581116 PMCID: PMC6970588 DOI: 10.3399/bjgpopen19x101654] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 05/23/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Several pathological processes contribute to lumbar radicular pain (LRP), commonly known as sciatica. It is not known how patients rationalise the experience of sciatica or understand the diagnosis. Providing clinicians with a better understanding of how patients conceptualise sciatica will help them to tailor information for patients on the management and treatment of the condition. AIM To understand patients' beliefs regarding their illness following a diagnosis of LRP, how these beliefs were developed, and the impact of illness beliefs on treatment beliefs. DESIGN & SETTING Qualitative interview study from a single NHS musculoskeletal interface service (in Wales, UK). METHOD Thirteen patients recently diagnosed with LRP were consecutively recruited. Individual semi-structured interviews were recorded and transcribed. Data were analysed using a thematic approach. RESULTS Four main themes were generated: (1) the illness experience (2) the concept of sciatica, (3) treatment beliefs, and (4) the desire for credible information. CONCLUSION The diagnosis of LRP is often communicated and understood within a compressive conceptual illness identity. Explaining symptoms with a compressive pathological model is easily understood by patients but may not accurately reflect the spectrum of pathological processes known to contribute to radicular pain. This model appears to inform patient beliefs about treatments. Clinicians should take care to fully explain the pathology prior to shared decision-making with patients.
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11
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Lin JH, Chen CC. Current challenges in diagnosis of lumbar radiculopathy. World J Anesthesiol 2018; 7:20-23. [DOI: 10.5313/wja.v7.i3.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/23/2018] [Accepted: 10/13/2018] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Jiann-Her Lin
- Department of Neurosurgery, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Surgery, School of Medicine, Taipei Medical University, Taipei, Taiwan
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Chih-Cheng Chen
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
- Taiwan Mouse Clinic, National Comprehensive Mouse Phenotyping and Drug Testing Center, Academia Sinica, Taipei, Taiwan
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12
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Muscle Atrophy Measurement as Assessment Method for Low Back Pain Patients. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1088:437-461. [PMID: 30390264 DOI: 10.1007/978-981-13-1435-3_20] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Low back pain is one of the most common pain disorders defined as pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, sometimes with accompanying leg pain. The meaning of the symptomatic atrophy of paraspinal muscles and some pelvic muscles has been proved. Nowadays, a need for new diagnostic tools for specific examination of low back pain patients is posited, and it has been proposed that magnetic resonance imaging assessment toward muscle atrophy may provide some additional information enabling the subclassification of that group of patients.
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Singh R, Yadav SK, Sood S, Yadav RK, Rohilla R. Evaluation of the Correlation of Magnetic Resonance Imaging and Electrodiagnostic Findings in Chronic Low Backache Patients. Asian J Neurosurg 2018; 13:1078-1083. [PMID: 30459872 PMCID: PMC6208195 DOI: 10.4103/ajns.ajns_169_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Low back pain (LBP) is one of the most common medical complaints and leading cause of workforce loss in many countries. Magnetic resonance imaging (MRI) is a highly sensitive method for the detection of lesions in the spine because of its excellent imaging of anatomical detail. However, MRI does not provide information about physiological nerve function and has relatively low specificity. Electrodiagnostic (EDX) study, including needle electromyography (EMG), is a specific test to assess the physiological functions of nerve roots or peripheral nerves. The aim of the present study was to correlate the electrophysiological and MRI findings in chronic low backache patients. Materials and Methods Fifty patients (26 males and 24 females) with mean age 33.54 ± 8.33 years with a history of LBP of minimum 3 consecutive months were evaluated with MRI and EDX (bilateral nerve conduction study of three nerves [tibial, peroneal, and sural nerve] and bilateral EMG of three muscles [paraspinal, tibialis anterior, vastus medialis]) studies. Results Twenty-seven patients showed disc involvement on MRI and 23 MRI were normal. Mean conduction velocity was mildly decreased in tibial and sural nerves in all the patients either with normal MRI or disc involvement on MRI. In disc involvement conduction velocity, decrease was more as compared to normal MRI. About 39% patients with normal MRI and 78% patients with disc involvement showed abnormal EMG. This data represented statistically significant association of EDX study with MRI (P < 0.05). Conclusions In patients with LBP, EDX studies are significantly more correlated with clinical data than MRI. Therefore, EMG may be a useful diagnostic tool to establish management protocols and prevent unnecessary interventions. EDX gives a better representation of physiological status of nerve and muscle, a supra added benefit which MRI lacks. However, MRI gives better visualization of anatomic parameters and structural details which may or may not be associated with chronic LBP.
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Affiliation(s)
- Roop Singh
- Department of Orthopaedic Surgery, Paraplegia and Rehabilitation, Government Medical College and Hospital, Chandigarh, India
| | - Sushil Kumar Yadav
- Department of Orthopaedic Surgery, Paraplegia and Rehabilitation, Government Medical College and Hospital, Chandigarh, India
| | - Sushma Sood
- Department of Physiology, Government Medical College and Hospital, Chandigarh, India
| | - Rohtas Kumar Yadav
- Department of Radiodiagnosis, Government Medical College and Hospital, Chandigarh, India
| | - Ravi Rohilla
- Department of Community Medicine, Government Medical College and Hospital, Chandigarh, India
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Splettstößer A, Khan MF, Zimmermann B, Vogl TJ, Ackermann H, Middendorp M, Maataoui A. Correlation of lumbar lateral recess stenosis in magnetic resonance imaging and clinical symptoms. World J Radiol 2017; 9:223-229. [PMID: 28634513 PMCID: PMC5441455 DOI: 10.4329/wjr.v9.i5.223] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 01/11/2017] [Accepted: 03/17/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the correlation of lateral recess stenosis (LRS) of lumbar segments L4/5 and L5/S1 and the Oswestry Disability Index (ODI).
METHODS Nine hundred and twenty-seven patients with history of low back pain were included in this uncontrolled study. On magnetic resonance images (MRI) the lateral recesses (LR) at lumbar levels L4/5 and L5/S1 were evaluated and each nerve root was classified into a 4-point grading scale (Grade 0-3) as normal, not deviated, deviated or compressed. Patient symptoms and disability were assessed using ODI. The Spearman’s rank correlation coefficient was used for statistical analysis (P < 0.05).
RESULTS Approximately half of the LR revealed stenosis (grade 1-3; 52% at level L4/5 and 42% at level L5/S1) with 2.2% and 1.9% respectively reveal a nerve root compression. The ODI score ranged from 0%-91.11% with an arithmetic mean of 34.06% ± 16.89%. We observed a very weak statistically significant positive correlation between ODI and LRS at lumbar levels L4/5 and L5/S1, each bilaterally (L4/5 left: rho < 0.105, P < 0.01; L4/5 right: rho < 0.111, P < 0.01; L5/S1 left: rho 0.128, P < 0.01; L5/S1 right: rho < 0.157, P < 0.001).
CONCLUSION Although MRI is the standard imaging tool for diagnosing lumbar spinal stenosis, this study showed only a weak correlation of LRS on MRI and clinical findings. This can be attributed to a number of reasons outlined in this study, underlining that imaging findings alone are not sufficient to establish a reliable diagnosis for patients with LRS.
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Skorupska E, Keczmer P, Łochowski RM, Tomal P, Rychlik M, Samborski W. Reliability of MR-Based Volumetric 3-D Analysis of Pelvic Muscles among Subjects with Low Back with Leg Pain and Healthy Volunteers. PLoS One 2016; 11:e0159587. [PMID: 27459688 PMCID: PMC4961367 DOI: 10.1371/journal.pone.0159587] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 07/06/2016] [Indexed: 01/21/2023] Open
Abstract
AIM Lately, the diagnostic value of magnetic resonance imaging, Lasègue sign and classic neurological signs have been considered not accurate enough to distinguish the radicular from non-radicular low back with leg pain (LBLP) and a calculation of the symptomatic side muscle volume has been indicated as a probable valuable marker. However, only the multifidus muscle volume has been calculated so far. The main objective of the study was to verify whether LBLP subjects presented symptomatic side pelvic muscle atrophy compared to healthy volunteers. The second aim was to assess the inter-rater reliability of 3-D manual method for segmenting and measuring the volume of the gluteus maximus, gluteus medius, gluteus minimus and piriformis muscles in both LBLP patients and healthy subjects. METHOD Two independent raters analyzed MR images of LBLP and healthy subjects towards muscle volume of four pelvic muscles, i.e. the piriformis, gluteus minimus, gluteus medius and gluteus maximus. For both sides, the MR images of the muscles without adipose tissue infiltration were manually segmented in 3-D medical images. RESULTS Symptomatic muscle atrophy was confirmed in only over 50% of LBLP subjects (gluteus maximus (p<0.001), gluteus minimus (p<0.01) and piriformis (p<0.05)). The ICC values indicated that the inter-rater reproducibility was greater than 0.90 for all measurements (LBLP and healthy subjects), except for the measurement of the right gluteus medius muscle in LBLP patients, which was equal to 0.848. CONCLUSION More than 50% of LBLP subjects presented symptomatic gluteus maximus, gluteus minimus and piriformis muscle atrophy. 3-D manual segmentation reliably measured muscle volume in all the measured pelvic muscles in both healthy and LBLP subjects. To answer the question of what kind of muscle atrophy is indicative of radicular or non-radicular pain further studies are required.
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Affiliation(s)
- Elżbieta Skorupska
- Department of Rheumatology and Rehabilitation, Poznan University of Medical Sciences, Poznan, Poland
| | - Przemysław Keczmer
- Department of Rheumatology and Rehabilitation, Poznan University of Medical Sciences, Poznan, Poland
| | - Rafał M. Łochowski
- Department of Mathematics and Mathematical Economics, Warsaw School of Economics, Warsaw, Poland
| | - Paulina Tomal
- Department of Rheumatology and Rehabilitation, Poznan University of Medical Sciences, Poznan, Poland
| | - Michał Rychlik
- Department of Virtual Engineering, Poznan University of Technology, Poznan, Poland
| | - Włodzimierz Samborski
- Department of Rheumatology and Rehabilitation, Poznan University of Medical Sciences, Poznan, Poland
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Diagnostic Accuracy of Lumbosacral Spine Magnetic Resonance Image Reading by Chiropractors, Chiropractic Radiologists, and Medical Radiologists. Spine (Phila Pa 1976) 2015; 40:E653-60. [PMID: 25803219 DOI: 10.1097/brs.0000000000000896] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A cross-sectional diagnostic accuracy study was conducted in 2 sessions. OBJECTIVE It is important to know whether it is possible to accurately detect "specific findings" on lumbosacral magnetic resonance (MR) images and whether the results of different observers are comparable. SUMMARY OF BACKGROUND DATA Health care providers frequently use magnetic resonance imaging in the diagnostic process of patients with low back pain. The use of MR scans is increasing. This leads to an increase in costs and to an increase in risk of inaccurately labeling patients with an anatomical diagnosis that might not be the actual cause of symptoms. METHODS A set of 300 blinded MR images was read by medical radiologists, chiropractors, and chiropractic radiologists in 2 sessions. Each assessor read 100 scans in round 1 and 50 scans in round 2. The reference test was an expert panel.For all analyses, the magnetic resonance imaging findings were dichotomized into "specific findings" or "no specific findings." For the agreement, percentage agreement and κ values were calculated and for validity, sensitivity, and specificity. Sensitivity analysis was done for classifications A and B (prevalence of 31% and 57%, respectively). RESULTS The intraobserver κ values for chiropractors, chiropractic radiologists, and medical radiologists were 0.46, 0.49, and 0.69 for A and 0.55, 0.75, and 0.64 for B, respectively.The interobserver κ values were lowest for chiropractors (0.28 for A, 0.37 for B) and highest for chiropractic radiologists (0.50 for A, 0.49 for B).The sensitivities of the medical radiologists, chiropractors, and chiropractic radiologists were 0.62, 0.71, and 0.75 for A and 0.70, 0.74, 0.84 for B, respectively.The specificities of medical radiologists, chiropractic radiologists, and chiropractors were 0.82, 0.77, and 0.70 for A and 0.74, 0.52, and 0.61 for B, respectively. CONCLUSION Agreement and validity of MR image readings of chiropractors and chiropractic and medical radiologists is modest at best. This study supports recommendations in clinical guidelines against routine use of magnetic resonance imaging in patients with low back pain. LEVEL OF EVIDENCE 3.
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Collen MR. A 40-Minute Phone Intervention. J Insur Med 2015; 45:110-2. [PMID: 27584847 DOI: 10.17849/insm-45-02-110-112.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This article recounts the experience of an 88-year-old woman with sciatic pain and her attempts to get it treated. Common interventions were utilized and failed, and back surgery was recommended. A patient advocate was consulted who suggested the need to begin to exercise and to reconsider other medical interventions. Within 2 months, she was pain-free and returned to her active lifestyle. The use of scientific evidence and common sense prevented unnecessary surgery and other costly medical treatments.
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Correlation of pain with objective quantification of magnetic resonance images in older adults with chronic low back pain. Spine (Phila Pa 1976) 2014; 39:469-75. [PMID: 24384652 PMCID: PMC4143235 DOI: 10.1097/brs.0000000000000181] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cross sectional study. OBJECTIVE The goal of this study is to identify relationships between objectively measured and subjectively scored parameters and reported pain. SUMMARY OF BACKGROUND DATA Studies have demonstrated the unreliability of magnetic resonance imaging (MRI)-based parameters to identify pathological pain generators of chronic low back pain, but they were based on visual inspection and subjective assessment of lumbar disc features. Advancements in computer image analysis provide objective measurements of lumbar disc features. METHODS Two radiologists evaluated 39 axial and sagittal T1- and T2-weighted MR images of patients with chronic axial low back pain (age, >65 yr) and graded 4 subjective lumbar disc parameters (T2 signal intensity, nucleus shape, Modic changes, and osteophyte formation) whose sum is the cumulative MRI score. Objective parameter, MRI index, was calculated as the product of the measured lumbar disc area and total disc MRI signal intensity. Discs were sorted from least to the most degenerated relative to each parameter. Pearson correlation coefficient and multiple linear regression analysis were performed between the reported pain score and each parameter. RESULTS The most and least degenerated discs in each patient, as assessed by MRI index, had the highest negative and positive correlation coefficient and regression weight contribution, respectively. All subjective parameters had low correlation coefficients and regression goodness of fit. CONCLUSION Although limited by small sample size, the objective parameter, MRI index, can be a potential imaging biomarker used to identify possible pain generators. This study presents a potential new application of MR imaging in identifying pain generators of patients with chronic low back pain.
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Clinical findings and electrodiagnostic testing in 108 consecutive cases of lumbosacral radiculopathy due to herniated disc. Neurophysiol Clin 2013; 43:205-15. [PMID: 24094906 DOI: 10.1016/j.neucli.2013.05.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Revised: 05/29/2013] [Accepted: 05/29/2013] [Indexed: 12/19/2022] Open
Abstract
STUDY AIM This prospective study aim to examine whether clinical findings and electrodiagnostic testing (EDX) in patients with lumbosacral monoradiculopathy due to herniated disc (HD) differ as a function of root involvement level (L5 vs. S1) and HD zone (paramedian vs. intraforaminal). PATIENTS AND METHODS All patients with L4, L5 or S1 monoradiculopathy were prospectively enrolled at four electromyography (EMG) labs over a 2-year period. The diagnosis was based on a congruence between patient history and MRI evidence of HD. We compared the sensitivities of clinical findings and EDX with respect to both root involvement level and HD zone. Multivariate logistic regression was performed in order to verify the association between abnormal EMG, clinical, and neuroradiological findings. RESULTS One hundred and eight patients (mean age 47.7 years, 55% men) were consecutively enrolled. Sensory loss in the painful dermatome was the most frequent finding at physical examination (56% of cases). EMG was abnormal in at least one muscle supplied by femoral and sciatic nerves in 45 cases (42%). Inclusion of paraspinal muscles increased sensitivity to only 49% and that of proximal muscles was useless. Motor and sensory neurography was seldom abnormal. The most frequent motor neurographic abnormalities were a delay of F-wave minimum latency and decrease in the compound muscle action potential amplitude from extensor digitorum brevis and abductor hallucis in L5 and S1 radiculopathies, respectively. Sensory neurography was usually normal, the amplitude of sensory nerve action potential was seldom reduced when HD injured dorsal root ganglion or postganglionic root fibres. Multivariate logistic regression analysis showed that EMG abnormalities could be predicted by myotomal muscular weakness, abnormal deep reflexes, and paraesthesiae. The only clinical and electrophysiological differences with respect to root involvement level concerned deep reflexes and motor neurography of deep peroneal and tibial nerves. CONCLUSIONS Only some EDX parameters are helpful for the diagnosis of lumbosacral radiculopathy. EMG was abnormal in less than 50% of cases and its abnormalities could be predicted by some clinical findings. However, neurography is useful as a tool for differential diagnosis between radiculopathy and more diffuse disorders of the peripheral nervous system (polyneuropathy, plexopathy).
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Magnetic Resonance Imaging versus Electrophysiologic Tests in Clinical Diagnosis of Lower Extremity Radicular Pain. ISRN NEUROSCIENCE 2013; 2013:952570. [PMID: 24967311 PMCID: PMC4045533 DOI: 10.1155/2013/952570] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 01/01/2013] [Indexed: 12/31/2022]
Abstract
Introduction. Radicular low back pain is one of the most common medical problems. The aim of this study was to evaluate the diagnostic accuracy of MRI and electrodiagnosis in lower extremity radicular pain in relation to history and clinical findings.
Methods. In this cross-sectional study, we studied 165 sciatalgic subjects. A comprehensive history and physical examinations were taken from the subjects and recorded, and then MRI scanning and electrodiagnostic (nerve conduction velocity and electromyography) tests were performed. Results. From 152 subjects who remained in the study, 67 cases (44.1%) had radicular pain in left lower limb, 46 (30.3%) in right, and 39 (25.6%) in both lower limbs. 104 cases (68.4%) had shown some type of abnormalities in both MRI and electrodiagnosis, 30 (19.7%) had shown this abnormality only in MRI, and 21 (13.8%) only in electrodiagnosis, while 10 cases (6.5%) had both normal MRI and electrodiagnostic studies. Coordination rates of MRI and electrodiagnosis with clinical findings were 58.6% and 89.5%, respectively. Conclusion. In many MRI negative but symptomatic subjects, electrodiagnosis has an important diagnostic value.
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Standardized terminology for disc disease. RADIOLOGIA 2012. [DOI: 10.1016/j.rxeng.2011.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Esene IN, Meher A, Elzoghby MA, El-Bahy K, Kotb A, El-Hakim A. Diagnostic performance of the medial hamstring reflex in L5 radiculopathy. Surg Neurol Int 2012; 3:104. [PMID: 23087820 PMCID: PMC3475886 DOI: 10.4103/2152-7806.100862] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 08/08/2012] [Indexed: 11/11/2022] Open
Abstract
Background: An avalanche of literature exists on almost every aspect of lumbar disc pathology but very limited studies have quantified the diagnostic performance of elements of clinical examination in predicting disc level, meticulously collated the reflex changes in lumbar disc herniation (LDH) as well as assessed the diagnostic performance of the medial hamstring reflex (MHR). Our study underscores the diagnostic performance of the MHR in L5 radiculopathy comparing its diagnostic power to that of the knee and ankle reflexes. Methods: One hundred consecutive patients operated for de novo LDH in our department between January and December 2011 were prospectively followed-up. A nested case control study was designed from our cohort to assess the performance of the MHR in L5 sciatica. All patients were examined by two independent examiners pre-operatively for the MHR and the results collated and correlated to MRI and intra-operative findings. Results: The MHR has a diagnostic performance intermediate to that of knee and ankle reflexes. The percentages correctly classified were respectively: 86%, 79% and 67% for the knee, MHR and ankle reflexes. The MHR is highly precise with an intra-rater reliability of 100% and inter-rater repeatability of above 90% and test-retest reproducibility of 100%. Conclusion: The MHR hitherto described as elusive has a high diagnostic performance and is a valid neurologic test that should be included in the routine neurologic examination of patients with suspected L5 radiculopathy.
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Suri P, Rainville J, Hunter DJ, Li L, Katz JN. Recurrence of radicular pain or back pain after nonsurgical treatment of symptomatic lumbar disk herniation. Arch Phys Med Rehabil 2012; 93:690-5. [PMID: 22464091 DOI: 10.1016/j.apmr.2011.11.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 11/09/2011] [Accepted: 11/09/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To determine recurrence rates of lower-extremity radicular pain after nonsurgical treatment of acute symptomatic lumbar disk herniation (LDH), and to identify predictors of recurrence. DESIGN Prospective inception cohort. SETTING Outpatient spine clinic. PARTICIPANTS Patients (N=79) reporting resolution of radicular pain after magnetic resonance imaging confirmation of LDH. INTERVENTIONS Individualized nonsurgical treatment tailored to the patient. All patients received education, but other treatments varied depending on the individual. MAIN OUTCOME MEASURES Resolution of radicular pain was defined as a pain-free period of ≥1 month. Patients who reported resolution of radicular pain within 1 year after seeking care for acute LDH were asked whether pain had recurred at 1 year after seeking care and were also reassessed 1 year after the time of resolution of radicular pain and 2 years after seeking care. Patients reported on recurrence and the date of recurrence, if any. We evaluated the 1-year incidence of recurrence, using Kaplan-Meier survival plots. We examined predictors of recurrence using bivariate and multivariate Cox proportional hazards models. We examined the secondary outcome of back pain recurrence using identical methods. RESULTS Twenty-five percent (95% confidence interval [CI], 15-35) of individuals with resolution of radicular pain for at least 1 month reported subsequent recurrence of pain within 1 year after resolution. The only factor independently associated with radicular pain recurrence was the number of months prior to resolution of pain (hazard ratio per month=1.24; 95% CI, 1.13-1.37; P<.001). The 1-year incidence of back pain recurrence was 43% (95% CI, 30-56), and older age decreased the hazard of recurrence. CONCLUSIONS Recurrence of radicular pain is relatively common after nonsurgical treatment of LDH and is predicted by longer time to initial resolution of pain.
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Affiliation(s)
- Pradeep Suri
- Veterans Affairs Boston Healthcare System, Boston, MA, USA.
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[Standardized terminology for disc disease]. RADIOLOGIA 2012; 54:503-12. [PMID: 22401946 DOI: 10.1016/j.rx.2011.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Revised: 10/31/2011] [Accepted: 11/03/2011] [Indexed: 11/21/2022]
Abstract
This article reviews the terminology used to describe morphological alterations in the intervertebral discs. Radiologists must be able to communicate information about the type, location, and severity of these alterations to medical and surgical clinicians. It is crucial to use simple, standard, and unified terminology to ensure comprehension not only among radiologists but also with professionals from the different specialties for whom the radiology reports are written (fundamentally traumatologists and neurosurgeons). This terminology will help ensure a more accurate diagnosis and better patient management.
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Leckie SK, Bechara BP, Hartman RA, Sowa GA, Woods BI, Coelho JP, Witt WT, Dong QD, Bowman BW, Bell KM, Vo NV, Wang B, Kang JD. Injection of AAV2-BMP2 and AAV2-TIMP1 into the nucleus pulposus slows the course of intervertebral disc degeneration in an in vivo rabbit model. Spine J 2012; 12:7-20. [PMID: 22023960 PMCID: PMC4896143 DOI: 10.1016/j.spinee.2011.09.011] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 07/27/2011] [Accepted: 09/07/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Intervertebral disc degeneration (IDD) is a common cause of back pain. Patients who fail conservative management may face the morbidity of surgery. Alternative treatment modalities could have a significant impact on disease progression and patients' quality of life. PURPOSE To determine if the injection of a virus vector carrying a therapeutic gene directly into the nucleus pulposus improves the course of IDD. STUDY DESIGN Prospective randomized controlled animal study. METHODS Thirty-four skeletally mature New Zealand white rabbits were used. In the treatment group, L2-L3, L3-L4, and L4-L5 discs were punctured in accordance with a previously validated rabbit annulotomy model for IDD and then subsequently treated with adeno-associated virus serotype 2 (AAV2) vector carrying genes for either bone morphogenetic protein 2 (BMP2) or tissue inhibitor of metalloproteinase 1 (TIMP1). A nonoperative control group, nonpunctured sham surgical group, and punctured control group were also evaluated. Serial magnetic resonance imaging (MRI) studies at 0, 6, and 12 weeks were obtained, and a validated MRI analysis program was used to quantify degeneration. The rabbits were sacrificed at 12 weeks, and L4-L5 discs were analyzed histologically. Viscoelastic properties of the L3-L4 discs were analyzed using uniaxial load-normalized displacement testing. Creep curves were mathematically modeled according to a previously validated two-phase exponential model. Serum samples obtained at 0, 6, and 12 weeks were assayed for biochemical evidence of degeneration. RESULTS The punctured group demonstrated MRI and histologic evidence of degeneration as expected. The treatment groups demonstrated less MRI and histologic evidence of degeneration than the punctured group. The serum biochemical marker C-telopeptide of collagen type II increased rapidly in the punctured group, but the treated groups returned to control values by 12 weeks. The treatment groups demonstrated several viscoelastic properties that were distinct from control and punctured values. CONCLUSIONS Treatment of punctured rabbit intervertebral discs with AAV2-BMP2 or AAV2-TIMP1 helps delay degenerative changes, as seen on MRI, histologic sampling, serum biochemical analysis, and biomechanical testing. Although data from animal models should be extrapolated to the human condition with caution, this study supports the potential use of gene therapy for the treatment of IDD.
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Affiliation(s)
- Steven K. Leckie
- Corresponding author. Department of Orthopedic Surgery, University of Pittsburgh Medical Center, BST E1641, 200 Lothrop St, Pittsburgh, PA 15213, USA. Tel.: (412) 648-1090. (S.K. Leckie)
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Obesity increases the risk of recurrent herniated nucleus pulposus after lumbar microdiscectomy. Spine J 2010; 10:575-80. [PMID: 20347400 DOI: 10.1016/j.spinee.2010.02.021] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Revised: 12/11/2009] [Accepted: 02/18/2010] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Recurrent herniation of the nucleus pulposus (HNP) frequently causes poor outcomes after lumbar discectomy. The relationship between obesity and recurrent HNP has not previously been reported. PURPOSE The purpose of this study was to investigate the association of obesity with recurrent HNP after lumbar microdiscectomy. STUDY DESIGN Retrospective Cohort. PATIENT SAMPLE We reviewed all cases of one- or two-level lumbar microdiscectomy from L2-S1 performed by a single surgeon with a minimum follow-up of 6 months. OUTCOME MEASURES The primary clinical outcomes were evidence of recurrent HNP on magnetic resonance imaging (MRI) and need for repeat surgery. METHODS All patients with recurrent radicular pain or new neurological deficits underwent a postoperative MRI scan. Recurrent HNP was defined as a HNP at the same side and same level as the index procedure. RESULTS Seventy-five patients were included in the study. The average body mass index (BMI) was 27.6+/-4.6. Thirty-two patients received an MRI scan. The time from operation to repeat MRI scan varied widely (3 days to 15 months). Eight patients (10.7%) had recurrent HNP. Four patients had persistent symptoms requiring reoperation (5.3%). The mean BMI of patients with recurrent HNP was significantly higher than that of those without recurrence (33.6+/-5.1 vs. 26.9+/-3.9, p<.001). In univariate analysis, obese patients (BMI >or=30) were 12 times more likely to have recurrent HNP than nonobese patients (odds ratio [OR]: 12.46, 95% confidence interval [CI]: 2.25-69.90). Obese patients were 30 times more likely to require reoperation (OR: 32.81, 95% CI: 1.67-642.70). Age, sex, smoking, and being a manual laborer were not significantly associated with recurrent HNP. A logistic regression analysis supported the findings of the univariate analysis. In a survival analysis using a Cox proportional hazards model, the hazard ratio of recurrent HNP for obese patients was 17 (OR: 17.08, 95% CI: 2.85-102.30, p=.002). CONCLUSIONS Obesity was a strong and independent predictor of recurrent HNP after lumbar microdiscectomy. Surgeons should incorporate weight loss counseling into their preoperative discussions with patients.
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Coster S, Bruijn SFTM, Tavy DLJ. Diagnostic value of history, physical examination and needle electromyography in diagnosing lumbosacral radiculopathy. J Neurol 2009; 257:332-7. [DOI: 10.1007/s00415-009-5316-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Revised: 08/27/2009] [Accepted: 08/31/2009] [Indexed: 11/30/2022]
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Sowa G, Westrick E, Rajasekhar AG, Woods B, Leckie S, Coelho P, Vo N, Studer R, Kang J. Identification of Candidate Serum Biomarkers for Intervertebral Disk Degeneration in an Animal Model. PM R 2009; 1:536-40. [DOI: 10.1016/j.pmrj.2009.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Revised: 03/18/2009] [Accepted: 03/28/2009] [Indexed: 11/17/2022]
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Tataroglu C, Bicerol B, Kiylioglu N, Ozkul A, Akyol A. Proximal femoral conductions in patients with lumbosacral radiculoplexus neuropathy. Clin Neurol Neurosurg 2007; 109:654-60. [PMID: 17573186 DOI: 10.1016/j.clineuro.2007.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Revised: 05/07/2007] [Accepted: 05/11/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Lumbosacral radiculoplexus neuropathy (DLRPN) is a rare form of neuropathy observed in diabetic and rarely non-diabetic patients. Pathophysiology and lesion location are not clearly understood. Our aim was to analyze proximal and distal femoral conductions in patients with DLRPN. METHODS Six patients with DLRPN, 14 patients with diabetic polyneuropathy and 25 healthy subjects were included in the study. We performed L3 monopolar root stimulation and femoral nerve trunk stimulation at the inguinal region and calculated lumbar plexus conduction time by subtracting the latency of compound muscle action potential (CMAP) of the vastus medialis evoked by femoral nerve stimulation from the latency of CMAP of vastus medialis evoked by L3 root stimulation. Additionally peak to peak amplitudes and areas of CMAPs were analyzed. RESULTS Electrophysiological examination showed that there was an axonal involvement in all patients with DLRPN. Prolonged lumbar plexus conduction time (in five extremities), and prolonged distal latency of the femoral nerve (in five extremities) probably due to secondary demyelination were also observed. Similar abnormalities were not observed in the diabetic polyneuropathy group. CONCLUSIONS DLRPN may affect different localizations on the peripheral nerves. L3 root stimulation may have an important role in the electrodiagnosis of DLRPN.
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Affiliation(s)
- Cengiz Tataroglu
- Adnan Menderes University, Medical Faculty, Department of Neurology, 09100 Aydin, Turkey.
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