Clinical indicators to identify neuropathic pain in low back related leg pain: a modified Delphi study

Predictors of outcome following an epidural steroid injection for disc-related sciatica: a Delphi consensus study

PURPOSE

Trial data shows modest reductions in leg pain, disability and surgery avoidance following epidural steroid injections (ESI) for severe sciatica. Despite their common use, there is no clear evidence about which patients are more likely to benefit from ESI. The aim of this study was to generate consensus on potential predictors of outcome following ESI for disc-related sciatica.

METHODS

A list of potential predictors of outcome was generated during a consensus meeting of seven experts. The items were subsequently presented in a two round on-line Delphi study to generate consensus among experts on which items are potential predictors of outcome. Consensus was defined as 70% agreement among participants.

RESULTS

Sixty-one items were generated during the consensus meeting. Of ninety experts invited to participate in the on-line Delphi study, 44 (48%) and 33 (73%) took part in rounds one and two respectively. Twenty-eight additional items suggested by participants in round one were included in round two. Overall, 14 items reached consensus reflecting domains of health, medication use, pain intensity, psychosocial factors, imaging findings and type of injection.

CONCLUSION

Based on expert consensus, items that can be routinely collected in clinical practice were identified as potential predictors of outcomes following ESI.

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

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

Establishment of the benchmarking tool for evaluating the operation of biorepositories for pathogenic resource using a modified Delphi method

In recent years, as the infectious diseases caused by pathogens such as novel coronavirus and mpox (formerly called monkeypox) spread globally, the significance of identification, preservation, and sharing of pathogenic resources become prominent. Along with the rapid development of biorepositories, it is imperative to evaluate their operation in a scientific manner. By using the literature review and modified Delphi method, this study develops a benchmarking tool for the comprehensive evaluation of the operation of biorepositories for pathogenic resources. The effective response rates of both rounds of expert surveys were 100 %. The authority coefficients (Cr) were 0.82 and 0.85, respectively, manifesting the reliability of consultation results. In the second-round survey, the Kendall's coefficient of concordance (Kendall's W) of all indicators ranged from 0.09 to 0.31 (P < 0.001), the comprehensive score ranged from 4.02 to 4.94, the standard deviation ranged from 0.21 to 0.77, and the coefficient of variation (CV) ranged from 0.04 to 0.22, indicating that the expert opinions reached consensus. The final benchmarking tool was composed of 4 primary indicators, 12 secondary indicators, and 65 tertiary indicators. The weights of the four primary indicators allocated through the rank-sum ratio method, namely organizational structure, management requirements, biobanking capacity, and sharing capacity, were 30.50 %, 30.08 %, 25.45 %, and 13.97 %, respectively. The benchmarking tool established in this study provides references for the comprehensive evaluation of the operation and puts forward advice for the sustainable development of biorepositories for pathogenic resources.

Diagnostic utility of diagnostic investigations to identify neuropathic pain in low back-related leg pain: protocol for a systematic review

INTRODUCTION

Neuropathic pain in low back-related leg pain has gained increasing interest in contemporary research. Identification of neuropathic pain in low back-related leg pain is essential to inform precision management. Diagnostic investigations are commonly used to identify neuropathic pain in low back-related leg pain; yet the diagnostic utility of these investigations is unknown. This systematic review aims to investigate the diagnostic utility of diagnostic investigations to identify neuropathic pain in low back-related leg pain.

METHODS AND ANALYSIS

This protocol has been designed and reported in accordance with the Cochrane Handbook for Diagnostic Test Accuracy studies, Centre for Reviews and Dissemination and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols checklist, respectively. The search strategy will involve two independent reviewers searching electronic databases (CINAHL, EMBASE, MEDLINE, Web of Science, Cochrane Library, AMED, Pedro), key journals (Spine, The Clinical Journal of Pain, PAIN, European Journal of Pain, The Journal of Pain, Musculoskeletal Science and Practice) and grey literature (British National Bibliography for report literature, OpenGrey, EThOS) from inception to 31 July 2023 to identify studies. Studies evaluating the diagnostic accuracy of diagnostic investigation to identify neuropathic pain in patients with low back-related leg pain will be eligible, studies not written in English will be excluded. The reviewers will extract the data from included studies, assess risk of bias (Quality Assessment of Diagnostic Accuracy Studies 2) and determine confidence in findings (Grading of Recommendations, Assessment, Development and Evaluation guidelines). Methodological heterogeneity will be assessed to determine if a meta-analysis is possible. If pooling of data is not possible then a narrative synthesis will be done.

ETHICS AND DISSEMINATION

Ethical approval is not required. Findings will be published in a peer-reviewed journal, presented at relevant conferences and shared with the Patient Partner Advisor Group at Western University, Canada.

PROSPERO REGISTRATION NUMBER

CRD42023438222.

Physiotherapy Screening for Referral of a Patient with Peripheral Arterial Disease Masquerading as Sciatica: A Case Report

Many causes potentially underline pain in the lower extremities, presenting a real challenge for primary care clinicians in the recognition of the source of the patient's complaints. Peripheral arterial disease (PAD) is defined as a total or partial blockage of the vessels that supply blood from the heart to the periphery. PAD of the lower extremities may masquerade as lumbosacral radiculopathy (LSR)-a common source of leg pain. Physiotherapists should be able to screen for PAD in people presenting with pain in the lower extremities. Failure to correctly screen for PAD could put the patient at risk of severe disability and possible permanent sequelae. This case report outlines the relevant concepts relating to the pathophysiology, screening, and differential diagnosis of PAD, and then further describes the relevant findings from the history and physical examination from the physiotherapist's perspective in a patient with an unusual symptom presentation. Although the patient was referred by a physician with a diagnosis of LSR, our case highlights the pivotal role of skilled physiotherapists in triaging a severe lower-limb PAD in need of referral. Therefore, this case report aims to increase clinicians' awareness of the clinical features of a complex case of PAD.

Low-back related leg pain: is the nerve guilty? How to differentiate the underlying pain mechanism

Low back pain (LBP) that radiates to the leg is not always related to a lesion or a disease of the nervous system (neuropathic pain): it might be nociceptive (referred) pain. Unfortunately, patients with low-back related leg pain are often given a variety of diagnoses (e.g. 'sciatica'; 'radicular pain'; pseudoradicular pain"). This terminology causes confusion and challenges clinical reasoning. It is essential for clinicians to understand and recognize predominant pain mechanisms. This paper describes pain mechanisms related to low back-related leg pain and helps differentiate these mechanisms in practice using clinical based scenarios. We illustrate this by using two clinical scenarios including patients with the same symptoms in terms of pain localization (i.e. low-back related leg pain) but with different underlying pain mechanisms (i.e. nociceptive versus neuropathic pain).