Randomized controlled trials in industrial low back pain relating to return to work. Part 2. Discogenic low back pain

Lumbar Disc Herniation Automatic Detection in Magnetic Resonance Imaging Based on Deep Learning

Background: Lumbar disc herniation (LDH) is among the most common causes of lower back pain and sciatica. The causes of LDH have not been fully elucidated but most likely involve a complex combination of mechanical and biological processes. Magnetic resonance imaging (MRI) is a tool most frequently used for LDH because it can show abnormal soft tissue areas around the spine. Deep learning models may be trained to recognize images with high speed and accuracy to diagnose LDH. Although the deep learning model requires huge numbers of image datasets to train and establish the best model, this study processed enhanced medical image features for training the small-scale deep learning dataset. Methods: We propose automatic detection to assist the initial LDH exam for lower back pain. The subjects were between 20 and 65 years old with at least 6 months of work experience. The deep learning method employed the YOLOv3 model to train and detect small object changes such as LDH on MRI. The dataset images were processed and combined with labeling and annotation from the radiologist's diagnosis record. Results: Our method proves the possibility of using deep learning with a small-scale dataset with limited medical images. The highest mean average precision (mAP) was 92.4% at 550 images with data augmentation (550-aug), and the YOLOv3 LDH training was 100% with the best average precision at 550-aug among all datasets. This study used data augmentation to prevent under- or overfitting in an object detection model that was trained with the small-scale dataset. Conclusions: The data augmentation technique plays a crucial role in YOLOv3 training and detection results. This method displays a high possibility for rapid initial tests and auto-detection for a limited clinical dataset.

The Effectiveness of Oral Corticosteroids for Management of Lumbar Radiating Pain: Randomized, Controlled Trial Study

BACKGROUND

Although both pregabalin and gabapentin are known to be useful for treating lumbar radiating pain and reducing the incidence of surgery, the oral corticosteroids sometimes offer a dramatic effect on severe radiating pain despite the lack of scientific evidence.

METHODS

A total of 54 patients were enrolled among 703 patients who complained of lumbar radiating pain. Twenty patients who received an oral corticosteroid was classified as group A and 20 patients who received the control drugs (pregabalin or gabapentin) as group B. Oswestry Disability Index (ODI), Revised Roland Morris disability questionnaire (RMDQ), Short Form 36 (SF-36) questionnaire, lumbar radiating pain, objective patient satisfaction, and objective improvement of patients or physicians were assessed at 2, 6, and 12 weeks after medication.

RESULTS

No difference in the sex ratio and age was observed between the groups (p = 0.70 and p = 0.13, respectively). Group A showed greater improvement in radiating pain after 2, 6, and 12 weeks than group B (p < 0.001, p = 0.001, and p < 0.001, respectively). No differences were observed between the groups in satisfaction at the beginning and 12 weeks after taking the medication (p = 0.062 and p = 0.061, respectively) and in objective improvement of patients and physicians (p = 0.657 and p = 0.748, respectively). Group A was less disabled and had greater physical health scores than group B (p = 0.014 and p = 0.017, respectively).

CONCLUSIONS

Oral corticosteroids for the treatment of lumbar radiating pain can be more effective in pain relief than gabapentin or pregabalin. The satisfaction of patients and physicians with the drug and objective improvement status were not inferior to that with gabapentin or pregabalin.

Effects of abdominal hollowing during stair climbing on the activations of local trunk stabilizing muscles: a cross-sectional study

Objective

To examine using surface electromyography whether stair climbing with abdominal hollowing (AH) is better at facilitating local trunk muscle activity than stair climbing without AH.

Methods

Twenty healthy men with no history of low back pain participated in the study. Surface electrodes were attached to the multifidus (MF), lumbar erector spinae, thoracic erector spinae, transverse abdominus - internal oblique abdominals (TrA-IO), external oblique abdominals (EO), and the rectus abdominis. Amplitudes of electromyographic signals were measured during stair climbing. Study participants performed maximal voluntary contractions (MVC) for each muscle in various positions to normalize the surface electromyography data.

Results

AH during stair climbing resulted in significant increases in normalized MVCs in both MFs and TrA-IOs (p<0.05). Local trunk muscle/global trunk muscle ratios were higher during stair climbing with AH as compared with stair climbing without AH. Especially, right TrA-IO/EO and left TrA-IO/EO were significantly increased (p<0.05).

Conclusion

Stair climbing with AH activates local trunk stabilizing muscles better than stair climbing without AH. The findings suggest that AH during stair climbing contributes to trunk muscle activation and trunk stabilization.

Military rank and the symptoms of lumbar disc herniation in young Korean soldiers

OBJECTIVE

There are many factors associated with the symptom presentation of lumbar disc herniation (LDH). However, there are only few reports regarding the clinical feature of LDH in military medicine. The objective of this study is to determine the factors that affected the symptoms of LDH in young Korean soldiers.

METHODS

One hundred thirty male soldiers, diagnosed with LDH, were enrolled in this study. They were divided into four groups, according to their military ranks: private, private first class, corporal, and sergeant. The visual analog scale for low back pain (VAS-LBP), the VAS for leg pain (VAS-LP), and the Oswestry Disability Index (ODI) were evaluated. The education level and military rank were also reviewed and their relationship with the degree of symptoms was investigated.

RESULTS

The mean age for the male subjects enrolled was 20.7 ± 1.2. The mean VAS-LBP, VAS-LP, and ODI were 6.6% ± 1.7%, 7.1% ± 1.9%, and 46.0% ± 16.3%, respectively. There was no statistically significant relationship between the degree of symptoms and the radiologic findings. However, the military rank had an inverse correlation with the VAS scores and the ODI (P < 0.05).

CONCLUSION

Our data showed that the military rank was associated with the symptom presentation of LDH and reflected the characteristics of military life.

Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline

STUDY DESIGN

Systematic review.

OBJECTIVE

To systematically assess benefits and harms of nonsurgical interventional therapies for low back and radicular pain.

SUMMARY OF BACKGROUND DATA

Although use of certain interventional therapies is common or increasing, there is also uncertainty or controversy about their efficacy.

METHODS

Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of local injections, botulinum toxin injection, prolotherapy, epidural steroid injection, facet joint injection, therapeutic medial branch block, sacroiliac joint injection, intradiscal steroid injection, chemonucleolysis, radiofrequency denervation, intradiscal electrothermal therapy, percutaneous intradiscal radiofrequency thermocoagulation, Coblation nucleoplasty, and spinal cord stimulation. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and by Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force.

RESULTS

For sciatica or prolapsed lumbar disc with radiculopathy, we found good evidence that chemonucleolysis is moderately superior to placebo injection but inferior to surgery, and fair evidence that epidural steroid injection is moderately effective for short-term (but not long-term) symptom relief. We found fair evidence that spinal cord stimulation is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. We found good or fair evidence that prolotherapy, facet joint injection, intradiscal steroid injection, and percutaneous intradiscal radiofrequency thermocoagulation are not effective. Insufficient evidence exists to reliably evaluate other interventional therapies.

CONCLUSION

Few nonsurgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials.

Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline

STUDY DESIGN

Systematic review.

OBJECTIVE

To systematically assess benefits and harms of surgery for nonradicular back pain with common degenerative changes, radiculopathy with herniated lumbar disc, and symptomatic spinal stenosis.

SUMMARY OF BACKGROUND DATA

Although back surgery rates continue to increase, there is uncertainty or controversy about utility of back surgery for various conditions.

METHODS

Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of the above therapies. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force.

RESULTS

For nonradicular low back pain with common degenerative changes, we found fair evidence that fusion is no better than intensive rehabilitation with a cognitive-behavioral emphasis for improvement in pain or function, but slightly to moderately superior to standard (nonintensive) nonsurgical therapy. Less than half of patients experience optimal outcomes (defined as no more than sporadic pain, slight restriction of function, and occasional analgesics) following fusion. Clinical benefits of instrumented versus noninstrumented fusion are unclear. For radiculopathy with herniated lumbar disc, we found good evidence that standard open discectomy and microdiscectomy are moderately superior to nonsurgical therapy for improvement in pain and function through 2 to 3 months. For symptomatic spinal stenosis with or without degenerative spondylolisthesis, we found good evidence that decompressive surgery is moderately superior to nonsurgical therapy through 1 to 2 years. For both conditions, patients on average experience improvement either with or without surgery, and benefits associated with surgery decrease with long-term follow-up in some trials. Although there is fair evidence that artificial disc replacement is similarly effective compared to fusion for single level degenerative disc disease and that an interspinous spacer device is superior to nonsurgical therapy for 1- or 2-level spinal stenosis with symptoms relieved with forward flexion, insufficient evidence exists to judge long-term benefits or harms.

CONCLUSION

Surgery for radiculopathy with herniated lumbar disc and symptomatic spinal stenosis is associated with short-term benefits compared to nonsurgical therapy, though benefits diminish with long-term follow-up in some trials. For nonradicular back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation, but associated with small to moderate benefits compared to standard nonsurgical therapy.

Modified straight leg raising test: a hypothetical clinical adjunct to distinguish two types of lumbar disc herniation preoperatively

There are two anatomically different types of lumbar disc herniation, contained and noncontained. The status of disc herniation not only has a place of in planning therapeutic procedure, but also appears prognostically important. However, it is difficult to distinguish these two types completely without surgery, even by imaging studies. As a hypothetical clinical adjunct, a modified straight leg raising test is described. This novel diagnostic aid is based on the pathogenesis of sciatica, and enlightened by the mechanisms of both traditional straight leg raising test and traction. We surmise that the mechanical compression caused by herniated disc is predominant in contained type; whereas the chemical inflammatory effect is more pronounced in the pathogenesis of sciatica in noncontained type. Thus, it is hypothesized that in patients with contained type, the symptoms of sciatica, and the angles of straight leg raising test would be different before and after traction. On the other hand, in patients with noncontained type, these clinical appearances could not improve significantly. According to the different symptoms, two types of disc herniation are expected to be distinguished by the straight leg raising test preoperatively. Combined with imaging studies, this hypothetical clinical adjunct is hoped to ameliorate the accuracy of diagnosis.

Surgical interventions for lumbar disc prolapse: updated Cochrane Review

STUDY DESIGN

An updated Cochrane Review.

OBJECTIVES

To assess the effects of surgical interventions for the treatment of lumbar disc prolapse.

SUMMARY OF BACKGROUND DATA

Disc prolapse accounts for 5% of low back disorders yet is one of the most common reasons for surgery. There is still little scientific evidence supporting some interventions.

METHODS

Use of standard Cochrane review methods to analyze all randomized controlled trials published up to January 1, 2007.

RESULTS

Forty randomized controlled trials (RCTs) and 2 quasi-RCTs were identified. Many of the early trials were of some form of chemonucleolysis, whereas the majority of the later studies either compared different techniques of discectomy or the use of some form of membrane to reduce epidural scarring. Four trials directly compared discectomy with conservative management, and these give suggestive rather than conclusive results. However, other trials show that discectomy produces better clinical outcomes than chemonucleolysis, and that in turn is better than placebo. Microdiscectomy gives broadly comparable results to standard discectomy. Recent trials of an interposition gel covering the dura (5 trials) and of fat (4 trials) show that they can reduce scar formation, although there is limited evidence about the effect on clinical outcomes. There is insufficient evidence on other percutaneous discectomy techniques to draw firm conclusions. Three small RCTs of laser discectomy do not provide conclusive evidence on its efficacy. There are no published RCTs of coblation therapy or transforaminal endoscopic discectomy.

CONCLUSION

Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are still unclear. The evidence for other minimally invasive techniques remains unclear except for chemonucleolysis using chymopapain, which is no longer widely available.

Surgical interventions for lumbar disc prolapse

BACKGROUND

Disc prolapse accounts for five percent of low-back disorders but is one of the most common reasons for surgery.

OBJECTIVES

The objective of this review was to assess the effects of surgical interventions for the treatment of lumbar disc prolapse.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Spine and abstracts of the main spine society meetings within the last five years. We also checked the reference lists of each retrieved articles and corresponded with experts. All data found up to 1 January 2007 are included.

SELECTION CRITERIA

Randomized trials (RCT) and quasi-randomized trials (QRCT) of the surgical management of lumbar disc prolapse.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial quality and extracted data from published papers. Additional information was sought from the authors if necessary.

MAIN RESULTS

Forty RCTs and two QRCTs were identified, including 17 new trials since the first edition of this review in 1999. Many of the early trials were of some form of chemonucleolysis, whereas the majority of the later studies either compared different techniques of discectomy or the use of some form of membrane to reduce epidural scarring. Despite the critical importance of knowing whether surgery is beneficial for disc prolapse, only four trials have directly compared discectomy with conservative management and these give suggestive rather than conclusive results. However, other trials show that discectomy produces better clinical outcomes than chemonucleolysis and that in turn is better than placebo. Microdiscectomy gives broadly comparable results to standard discectomy. Recent trials of an inter-position gel covering the dura (five trials) and of fat (four trials) show that they can reduce scar formation, though there is limited evidence about the effect on clinical outcomes. There is insufficient evidence on other percutaneous discectomy techniques to draw firm conclusions. Three small RCTs of laser discectomy do not provide conclusive evidence on its efficacy, There are no published RCTs of coblation therapy or trans-foraminal endoscopic discectomy.

AUTHORS' CONCLUSIONS

Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are still unclear. Microdiscectomy gives broadly comparable results to open discectomy. The evidence on other minimally invasive techniques remains unclear (with the exception of chemonucleolysis using chymopapain, which is no longer widely available).

The development of an evidence-based patient booklet for patients undergoing lumbar discectomy and un-instrumented decompression

Post-operative management after lumbar surgery is inconsistent leading to uncertainty amongst surgeons and patients about post-operative restrictions, reactivation, and return to work. This study aimed to review the evidence on post-operative management, with a view to developing evidence-based messages for a patient booklet on post-operative management after lumbar discectomy or un-instrumented decompression. A systematic literature search produced a best-evidence synthesis of information and advice on post-operative restrictions, activation, rehabilitation, and expectations about outcomes. Evidence statements were extracted and developed into patient-centred messages for an educational booklet. The draft text was evaluated by peer and patient review. The literature review found little evidence for post-operative activity restrictions, and a strong case for an early active approach to post-operative management. The booklet was built around key messages derived from the literature review and aimed to reduce uncertainty, promote positive beliefs, encourage early reactivation, and provide practical advice on self-management. Feedback from the evaluations were favourable from both review groups, suggesting that this evidence-based approach to management is acceptable and it has clinical potential.

Surgical interventions for lumbar disc prolapse

BACKGROUND

Disc prolapse accounts for five percent of low-back disorders but is one of the most common reasons for surgery.

OBJECTIVES

The objective of this review was to assess the effects of surgical interventions for the treatment of lumbar disc prolapse.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Spine and abstracts of the main spine society meetings within the last five years. We also checked the reference lists of each retrieved articles and corresponded with experts. All data found up to 1 June 2006 are included.

SELECTION CRITERIA

Randomized trials (RCT) and quasi-randomized trials (QRCT) of the surgical management of lumbar disc prolapse.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial quality and extracted data from published papers. Additional information was sought from the authors if necessary.

MAIN RESULTS

Thirty-nine RCTs and two QRCTs were identified, including 16 new trials since the first edition of this review in 1999. Many of the early trials were of some form of chemonucleolysis, whereas the majority of the later studies either compared different techniques of discectomy or the use of some form of membrane to reduce epidural scarring. Despite the critical importance of knowing whether surgery is beneficial for disc prolapse, only three trials have directly compared discectomy with conservative management and these give suggestive rather than conclusive results. However, other trials show that discectomy produces better clinical outcomes than chemonucleolysis and that in turn is better than placebo. Microdiscectomy gives broadly comparable results to standard discectomy. Recent trials of an inter-position gel covering the dura (five trials) and of fat (four trials) show that they can reduce scar formation, though there is limited evidence about the effect on clinical outcomes. There is insufficient evidence on other percutaneous discectomy techniques to draw firm conclusions. Three small RCTs of laser discectomy do not provide conclusive evidence on its efficacy, There are no published RCTs of coblation therapy or trans-foraminal endoscopic discectomy.

AUTHORS' CONCLUSIONS

Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are still unclear. Microdiscectomy gives broadly comparable results to open discectomy. The evidence on other minimally invasive techniques remains unclear (with the exception of chemonucleolysis using chymopapain, which is no longer widely available).

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

OBJECTIVE

The objective of this study was to systematically review the literature to assess the efficacy of nonsurgical spinal decompression achieved with motorized traction for chronic discogenic lumbosacral back pain.

DESIGN

Computer-aided systematic literature search of MEDLINE and the Cochrane collaboration for prospective clinical trials on adults with low back pain in the English literature from 1975 to October 2005. Methodologic quality for each study was assessed. Studies were included if the intervention group received motorized spinal decompression and the comparison group received sham or another type of nonsurgical treatment.

RESULTS

Data from 10 studies were fully analyzed. Seven studies were randomized controlled trials using various apparatus types. Because of this low number, we also analyzed three nonrandomized case series studies of spinal decompression systems. As the overall quality of studies was low and the patient groups heterogeneous, a meta-analysis was not appropriate and a qualitative review was undertaken. Sample sizes averaged 121 patients (range 27-292), with six of the seven randomized studies reporting no difference with motorized spinal decompression and one study reporting reduced pain but not disability. The three unrandomized studies (no control group) of motorized spinal decompression found a 77% to 86% reduction in pain.

CONCLUSIONS

These data suggest that the efficacy of spinal decompression achieved with motorized traction for chronic discogenic low back pain remains unproved. This may be, in part, due to heterogeneous patient groups and the difficulties involved in properly blinding patients to the mechanical pulling mechanism. Scientifically more rigorous studies with better randomization, control groups, and standardized outcome measures are needed to overcome the limitations of past studies.

Effect of continuous lumbar traction on the size of herniated disc material in lumbar disc herniation

We investigated the effects of continuous lumbar traction in patients with lumbar disc herniation on clinical findings, and size of the herniated disc measured by computed tomography (CT). In this prospective, randomized, controlled study, 46 patients with lumbar disc herniation were included, and randomized into two groups as the traction group (24 patients), and the control group (22 patients). The traction group was given a physical therapy program and continuous lumbar traction. The control group was given the same physical therapy program without traction, for the same duration of time. Data for the clinical symptoms and signs were collected before and after the treatment together with calculation of a herniation index, from the CT images that showed the size of the herniated disc material. In the traction group, most of the clinical findings significantly improved with treatment. Size of the herniated disc material in CT decreased significantly only in the traction group. In the traction group the herniation index decreased from 276.6+/-129.6 to 212.5+/-84.3 with treatment (p<0.01). In the control group, pretreatment value was 293.4+/-112.1, and it decreased to 285.4+/-115.4 after the treatment (p>0.05). Patients with greater herniations tended to respond better to traction. In conclusion, lumbar traction is both effective in improving symptoms and clinical findings in patients with lumbar disc herniation and also in decreasing the size of the herniated disc material as measured by CT.

Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials

Background

Osteopathic manipulative treatment (OMT) is a distinctive modality commonly used by osteopathic physicians to complement their conventional treatment of musculoskeletal disorders. Previous reviews and meta-analyses of spinal manipulation for low back pain have not specifically addressed OMT and generally have focused on spinal manipulation as an alternative to conventional treatment. The purpose of this study was to assess the efficacy of OMT as a complementary treatment for low back pain.

Methods

Computerized bibliographic searches of MEDLINE, EMBASE, MANTIS, OSTMED, and the Cochrane Central Register of Controlled Trials were supplemented with additional database and manual searches of the literature.

Six trials, involving eight OMT vs control treatment comparisons, were included because they were randomized controlled trials of OMT that involved blinded assessment of low back pain in ambulatory settings. Data on trial methodology, OMT and control treatments, and low back pain outcomes were abstracted by two independent reviewers. Effect sizes were computed using Cohen's d statistic and meta-analysis results were weighted by the inverse variance of individual comparisons. In addition to the overall meta-analysis, stratified meta-analyses were performed according to control treatment, country where the trial was conducted, and duration of follow-up. Sensitivity analyses were performed for both the overall and stratified meta-analyses.

Results

Overall, OMT significantly reduced low back pain (effect size, -0.30; 95% confidence interval, -0.47 – -0.13; P = .001). Stratified analyses demonstrated significant pain reductions in trials of OMT vs active treatment or placebo control and OMT vs no treatment control. There were significant pain reductions with OMT regardless of whether trials were performed in the United Kingdom or the United States. Significant pain reductions were also observed during short-, intermediate-, and long-term follow-up.

Conclusion

OMT significantly reduces low back pain. The level of pain reduction is greater than expected from placebo effects alone and persists for at least three months. Additional research is warranted to elucidate mechanistically how OMT exerts its effects, to determine if OMT benefits are long lasting, and to assess the cost-effectiveness of OMT as a complementary treatment for low back pain.

Far-Lateral disk herniation: case report, review of the literature, and a description of nonsurgical management

OBJECTIVE

To review the history and examination of a far-lateral lumbar intervertebral disk herniation (FLLIDH), as well as the treatment and outcomes of a nonsurgical approach.

CLINICAL FEATURES

A 60-year-old healthy male subject had a 3-week history of right buttock and calf pain. He initially had a left lateral list and asymmetrical pelvic landmarks. Range of motion (ROM) of the lumbar spine revealed full and pain-free lumbar flexion, right-sided pain with lumbar extension and left side bending, and painful and restricted left side bending. Neurologic examination was unremarkable.

INTERVENTION AND OUTCOME

The patient was treated with a lumbar epidural and nerve root injection, as well as manipulation. Physical therapy consisted of deweighting treadmill, autotraction, and strengthening exercises. Outcomes were measured by using the Modified Oswestry Questionnaire, as well as a numerical pain rating scale. His initial Oswestry was 73%, pain 9/10 at presentation. Upon discharge, the Oswestry was 0% and pain was rated as 0/10.

CONCLUSION

A significant decrease was noted in both the Oswestry Questionnaire, as well as the pain rate. The patient returned to running on alternate days for a minimum of 30 minutes, which was his primary goal. This case demonstrated a positive outcome using a multidisciplinary approach in a patient diagnosed with a FLLIDH. He obtained his goals and his function was fully restored.

Injections and surgical therapy in chronic pain

OBJECTIVE

The purpose of this review was to determine how effective surgery and injection therapy are in the management of chronic pain.

METHODOLOGY

A standardized literature search identified seven systematic reviews of the literature and six randomized controlled trials to provide evidence about surgery and injection therapy for chronic pain.

RESULTS

Some study subjects had highly specific diagnoses, whereas other study subject groups had nonspecific pain, including multiple conditions. The timing of treatment interventions was generally unclear, and few studies analyzed subgroups. Overall, there was a lack of methodologically sound studies of surgery and injection therapies.

CONCLUSIONS

Standard discectomy compared with conservative treatment for proven disc herniation (< or = 1 year) and local triamcinolone injection for lateral epicondylitis (< or = 12 weeks) are both effective for pain relief (level 2). There was limited evidence of effectiveness (level 3) of intraoperative steroid at discectomy, epidural steroid injection for sciatica with low back pain, caudal steroid injection for low back pain, local glycosaminoglycan polyphosphate injection for lateral epicondylitis, intraarticular steroid injection for shoulder arthritis, subacromial steroid injections for rotator cuff tendinitis, nonspecific injections for painful shoulder, systemic growth hormone for fibromyalgia, and intravenous adenosine for fibromyalgia. There was limited evidence (level 3) that there is no additional benefit of adding steroid to local anesthetic in caudal epidural injections. There is limited evidence (level 3) that intravenous adenosine is ineffective for fibromyalgia. The remaining evidence was inadequate (level 4a) or contradictory (level 4b).

Evaluation and management of occupational low back disorders

This clinical practice review of occupational low back disorders describes work-related risk factors, occupational history, physical evaluation, clinical tests, diagnosis, care, and prevention. It is part of a quality assurance (QA) and quality improvement (QI) effort to establish exemplary occupational practice standards. It emphasizes the involvement of occupational medicine physicians in exposure assessment, care of injured workers, and disease prevention. Important occupational risk factors such as lifting, awkward body posture and vibration, in addition to psychosocial, socio-economic and other factors are summarized. The focus is on mechanical back disorders. Return-to-work, rehabilitation and prevention strategies are discussed as part of integrated disability management involving the injured worker, the primary care provider, employers and other relevant parties.

The Cochrane review of surgery for lumbar disc prolapse and degenerative lumbar spondylosis

STUDY DESIGN

A Cochrane review of randomized controlled trials.

OBJECTIVES

To collate the scientific evidence on surgical management for lumbar-disc prolapse and degenerative lumbar spondylosis.

SUMMARY OF BACKGROUND DATA

Surgical investigations and interventions account for as much as one third of the health care costs for spinal disorders, but the scientific evidence for most procedures still is unclear.

METHODS

A highly sensitive search strategy identified all published randomized controlled trials. Cochrane methodology was used for meta-analysis of the results.

RESULTS

Twenty-six randomized controlled trials of surgery for lumbar disc prolapse and 14 trials of surgery for degenerative lumbar spondylosis were identified. Methodologic weaknesses were found in many of the trials. Only one trial directly compared discectomy and conservative management. Meta-analyses showed that surgical discectomy produces better clinical outcomes than chemonucleolysis, which is better than placebo. Three trials showed no difference in clinical outcomes between microdiscectomy and standard discectomy, but in three other studies, both produced better results than percutaneous discectomy. Three trials showed that inserting an interposition membrane after discectomy does not significantly reduce scar formation or alter clinical outcomes. Five heterogeneous trials on spinal stenosis and degenerative spondylolisthesis permit very limited conclusions. There were nine trials of instrumented versus noninstrumented fusion: Meta-analysis showed that instrumentation may facilitate fusion but does not improve clinical outcomes.

CONCLUSIONS

There is now strong evidence on the relative effectiveness of surgical discectomy versus chemonucleolysis versus placebo. There is considerable evidence on the clinical effectiveness of discectomy for carefully selected patients with sciatica caused by lumbar disc prolapse that fails to resolve with conservative management. There is no scientific evidence on the effectiveness of any form of surgical decompression or fusion for degenerative lumbar spondylosis compared with natural history, placebo, or conservative management. The Cochrane reviews will be updated continuously as other trials become available.

Randomized trial comparing interferential therapy with motorized lumbar traction and massage in the management of low back pain in a primary care setting

STUDY DESIGN

A randomized trial designed to compare interferential therapy with motorized lumbar traction and massage management for low back pain in a primary care setting.

OBJECTIVE

To measure and compare the outcome of interferential therapy and management by motorized lumbar traction and massage.

SUMMARY OF BACKGROUND DATA

Management of low back pain by interferential therapy and motorized lumbar traction and massage is common in Germany. No reports of previous randomized trials for the outcome from interferential therapy were found.

METHODS

Consenting patients were randomly assigned into one of two groups. A pretreatment interview was performed by the patient using a computer-based questionnaire. It also incorporated the Oswestry Disability Index and a pain visual analog scale. Management consisted of six sessions over a 2- to 3-week period. Oswestry Disability Indexes and pain visual analog scale scores also were obtained immediately after and at 3 months after treatment.

RESULTS

A total of 152 patients were recruited. The two treatment groups had similar demographic and clinical baseline characteristics. The mean Oswestry Disability Index before treatment was 30 for both groups (n = 147). After treatment, this had dropped to 25, and, at 3 months, were 21 (interferential therapy) and 22 (motorized lumbar traction and massage). The mean pain visual analog scale score before treatment was 50 (interferential therapy) and 51 (motorized lumbar traction and massage). This had dropped, respectively, to 46 and 44 after treatment and to 42 and 39 at 3 months.

CONCLUSIONS

This study shows a progressive fall in Oswestry Disability Index and pain visual analog scale scores in patients with low back pain treated with either-interferential therapy or motorized lumbar traction and massage. There was no difference in the improvement between the two groups at the end of treatment. Although there is evidence from several trials that traction alone is ineffective in the management of low back pain, this study could not exclude some effect from the concomitant massage.

Occupational role performance in persons with back pain

PURPOSE

Back pain is a major cause of work disability but there is little data on the impact of back pain among persons who are working. The purpose of this study was to develop a measure of occupational role performance for individuals with back pain and to examine its relationship with sociodemographic and work-related factors.

METHOD

Item analysis and reduction resulted in a short, eight-item Occupational Role Questionnaire (ORQ) consisting of two scales, a productivity scale and a satisfaction with work scale. The scales had good internal consistency and correlated as expected with the Roland and Morris Disability Scale.

RESULTS

In a multivariate logistic model, significant negative effects on work satisfaction were observed for age 30-39 years relative to age 50+, having a job that required lifting, and the level of disability.

CONCLUSION

The ORQ may have applications in studying the consequences of back pain and other chronic conditions in the workplace.

Randomized controlled trials in industrial low back pain. Part 3. Subacute/chronic pain interventions

The most significant costs attributed to settlement of workplace back injury claims are related to chronic low back pain (LBP). Unfortunately, our knowledge of this fact has not led to a reduction of the considerable costs paid out annually by employers and insurers to deal with the chronic pain syndrome. This article is the third in a series of reviews on randomized controlled trials found in the English language medical literature between 1975 and 1993. Of more than 4,000 LBP citations, 35 studies met-the selection criteria of randomization, reasonable concurrent controls and work return comparisons. This review focuses on the 12 studies utilizing nonsurgical interventions for subacute and chronic LBP, including multidisciplinary pain clinics, exercise, cognitive-behavioral strategies, and others. A 26-point quality system was again used to compare the methodologic rigor of each study. The majority of prospective studies investigating return to work after chronic LBP have methodological limitations; additional research is clearly needed to more confidently answer the question of what interventions improve work capacity in patients with chronic LBP.

Industrial rehabilitation medicine. 2. Case studies in occupational low back pain

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on industrial rehabilitation medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. The evaluation and management of patients presenting with low back pain are skills that practicing physiatrists need to acquire. This chapter gives a step-by-step format, along with the thought processes involved, for managing patients with three types of low back pain presentations.