SEARCH · PubMed Health
Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.
Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.
Pelvic schwannoma is a rare cause of sciatic pain. We report a case of retroperitoneal pelvic schwannoma presenting with chronic sciatica which was diagnosed and monitored radiologically for several years before successful surgical resection.
OBJECTIVE: To determine predictive factors for radical treatment (nucleolysis or surgery) after in-hospital conservative management of low back pain with sciatica (LBPS). PATIENTS AND METHODS: A standardized form was used to collect data on 134 patients admitted for conservative treatment of LBPS. Subsequent radical procedures were recorded 11 to 24 months after discharge. RESULTS: Forty-seven patients required radical treatment after discharge. Significant risk factors for radical treatment in the univariate analysis were taller stature, use of a lumbar support, more preadmission epidural injections, a positive straight leg-raising test, and a disk herniation diameter of at least 50% of the spinal canal diameter. Protective factors were onset within the month preceding admission and normal range of motion of the lumbar spine. In the multivariate analysis, symptom duration longer than one month, use of a lumbar support prior to admission, and a positive straight leg-raising test were associated with radical treatment. A positive straight leg-raising test was the only significant clinical risk factor in the subset of patients investigated by computed tomography (CT). When CT findings were added to the model, only size of the herniation was significant. CONCLUSION: Sixty-five percent of patients admitted for conservative treatment of LBPS do not receive radical treatment during a mean follow-up of 18 months. Several factors are associated with the likelihood of radical treatment.
BACKGROUND AND OBJECTIVES: It has been claimed that epiduroscopy offers an ideal combination of diagnostic and therapeutic interventions in one session. We prospectively evaluated whether abnormalities at the lumbar level as diagnosed by magnetic resonance imaging (MRI) are confirmed by epiduroscopy, and assessed if targeted epidural injection of medication alleviates sciatic pain. METHODS: A flexible, 0.9-mm fiberoptic endoscope was introduced through a disposable steering shaft into the caudal epidural space and advanced until the targeted spinal nerve was identified. Adhesions were mechanically mobilized under direct vision, and a mixture of 120 mg methylprednisolone acetate, 600 IU hyaluronidase, and 150 microg clonidine was applied locally. Pain scores were measured by visual analog scale (VAS) and global subjective efficacy rating. RESULTS: Nineteen of 20 patients studied showed adhesions via epiduroscopy. In 8 patients, 6 of whom had never undergone surgery, these were not detected with earlier magnetic resonance imaging. Six patients showed concomitant signs of active root inflammation. Of 20 patients treated with a targeted epidural injection, 11 patients (55%) experienced significant pain relief at 3 months. This was maintained at 6, 9, and 12 months for 8 (40%), 7 (35%), and 7 (35%) patients, respectively. Mean VAS at 3 months was significantly reduced (n = 20; DeltaVAS = 3.55; P <.0001), and this persisted at 12 months (DeltaVAS = 1.99, P =.0073). CONCLUSIONS: Epiduroscopy is of value in the diagnosis of spinal root pathology. In sciatica, adhesions unreported by MRI can be identified. Targeted epidural medication, administered near the compromised spinal nerve, results in substantial and prolonged pain relief.
BACKGROUND AND METHODS: Bed rest is widely advocated for sciatica, but its effectiveness has not been established. To study the effectiveness of bed rest in patients with a lumbosacral radicular syndrome of sufficient severity to justify treatment with bed rest for two weeks, we randomly assigned 183 subjects to either bed rest or watchful waiting for this period. The primary outcome measures were the investigator's and patient's global assessments of improvement after 2 and 12 weeks, and the secondary outcome measures were changes in functional status and in pain scores (after 2, 3, and 12 weeks), absenteeism from work, and the need for surgical intervention. Neither the investigators who assessed the outcomes nor those involved in data entry and analysis were aware of the patients' treatment assignments. RESULTS: After two weeks, 64 of the 92 patients in the bed-rest group (70 percent) reported improvement, as compared with 59 of the 91 patients in the control (watchful-waiting) group (65 percent) (adjusted odds ratio for improvement in the bed-rest group, 1.2; 95 percent confidence interval, 0.6 to 2.3). After 12 weeks, 87 percent of the patients in both groups reported improvement. The results of assessments of the intensity of pain, the bothersomeness of symptoms, and functional status revealed no significant differences between the two groups. The extent of absenteeism from work and rates of surgical intervention were similar in the two groups. CONCLUSIONS: Among patients with symptoms and signs of a lumbosacral radicular syndrome, bed rest is not a more effective therapy than watchful waiting.
OBJECTIVE: To describe 3 cases of discogenic low back pain and leg pain in which the centralization phenomenon was used in determining chiropractic treatment and prognosis. CLINICAL FEATURES: Three men with low back pain and sciatica, positive straight leg raise, mild neurologic deficits, and evidence of discogenic disease requested chiropractic treatment. Two of the patients exhibited centralization of pain on provocation testing; the third did not. INTERVENTION AND OUTCOME: All patients were treated with chiropractic side-posture manipulation, ancillary therapies, and pain medications. The 2 subjects whose pain centralized had excellent outcomes to treatment. The one whose pain did not centralize had a poor outcome and eventually required surgery. CONCLUSION: Assessment of the centralization phenomenon provided valuable diagnostic and prognostic information regarding chiropractic side-posture manipulation in this case series.
An audit was conducted to determine if epidural injections for back pain and sciatica were practised in accordance with guidelines prescribed by the National Health and Medical Research Council (NHMRC). More than 80% of injections were used for conditions for which they were not indicated, and which the NHMRC considers experimental. Most commonly, epidural injections afforded no benefit to the patients, yet were often repeated. In no instance was informed consent recorded as recommended by the NHMRC. The practice of epidural injections is dissonant both with the evidence-based literature and with recommended guidelines, and squanders both financial and professional resources.
A case report of a patient who developed cauda equina syndrome following pelvic traction for acute sciatica is presented. A good outcome was obtained with prompt surgical decompression. This case illustrates the potential dangers of traction, which is frequently employed in the management of acute back pain.
OBJECTIVE: We identified several problems associated with percutaneous lumbar disc decompression (PLDD) based on a study of patients who required salvage operations for complications after undergoing PLDD at an outside institution. BACKGROUND DATA: PLDD has been performed as a new treatment for intervertebral disc herniation in recent years, and its safety and effectiveness are in the process of being established. Because the procedure is simple to perform under local anesthesia, inappropriate irradiation and application to patients for whom it is not indicated have sometimes resulted in a poor outcome and serious complications. METHODS: The patients comprised 10 with lumbar disc herniation and three with lumbar spondylolisthesis. We analyzed the magnetic resonance (MR) imaging and operative findings as well as the pathological features of surgically obtained disc specimens and studied their relationships with the clinical outcomes of the operations. RESULTS: Initial examination of all patients at our hospital showed that PLDD had no effect on low back pain or sciatica. In patients who showed MR signal changes in the end-plate, the pathological examination revealed extensive necrosis of cartilage and bone. During salvage operations, severe adhesion of herniated masses to nerve roots was often observed, with carbonized disc tissue surrounding the nerve roots and might have their nerve root injured thermally. CONCLUSION: PLDD is associated with significant risk of disc, end-plate, and nerve root injuries, contrary to the general belief that the procedure is minimally invasive. Our findings highlight the need for careful diagnosis and sufficient technical skill when selecting PLDD as a treatment option.
A double-blind control study of lumbar traction for sciatica has been carried out. Although there is a tendency for traction to produce improvement in pain and straight-leg raise the extent does not achieve statistical significance. Changing 'control' patients to 'treatment' seemed to produce worthwhile relief of pain for all who were not already improving. It is suggested that a large trial using more discriminating criteria might delineate a group of patients susceptible to help by traction.
A randomized trial of lumbar epidural injections for the treatment of acute sciatic pain was carried out. All the patients had unilateral sciatica for less than six months and had never previously been treated in hospital for their backs. The treatments used were 20 ml normal saline, 80 mg Depomedrone in normal saline made up to 20 ml, 20 ml, 20 ml 0.25% bupivacaine solution and needling with a standard Touhy injection needle into the interspinous ligament but with no injection. The patients improved at about the same rate for all four treatments. Overall, 75% of the patients improved or were cured. As some of these were in the group treated by needling of the interspinous ligament, it seems likely that the epidural injections administered achieved effects partially as a placebo and partially by virtue of the natural history of the acute sciatic syndrome.
A controlled trial of continuous lumbar traction in the treatment of back pain and sciatica showed similar improvements in both the treated group (weighted traction) and the control group (simulated traction). The findings of this study question the justification of admitting patients with back pain into hospitals for purposes of traction alone.
Fifty consecutive patients starting treatment for sciatica with epidural injections of steroid and local anaesthetic underwent concomitant epidurography. The prognostic potential of this combination was investigated. Epidurography was confirmed as a safe out-patient procedure. Incorrect needle siting accounted for five total and two partial failures. The procedure was found to be a sensitive investigation, 36 showing definite abnormalities. It was of particular value in the diagnosis of lateral canal stenosis. However, it was found to have no prognostic value. For 12 of 16 patients requiring invasive therapy, it was considered that epidurography would have obviated later radiculography had the results been known. It is suggested that the combination of this out-patient investigation with the last of three epidural anaesthetic injections in patients whose symptoms persist, represents an improvement in management both financially and in terms of patient convenience.
Two patients are described in whom sciatica was caused by non-Hodgkin's lymphoma involving the spinal epidural space. Systematic investigation revealed no evidence of lymphoma in other sites.
Twenty patients with sciatica associated with anomalous lumbar nerve roots were reviewed with an average follow-up of 26.3 months. All patients had predominantly leg pain and their nerve root anomaly was known preoperatively. Overall success rate was 65% but was increased to 80% in patients with concurrent disk herniation. Improved results of surgical decompression were most consistently associated with concurrent disk herniation whereas other factors such as more extensive decompression were less strongly correlated. Surgery should only be offered with these results in mind.
Knee flexion of the leg when a patient with sciatica bends to reach the floor is objective evidence of lumbar spinal nerve root compression. Contralateral sciatic scoliotic list usually accompanies the finding, which should be known as a positive knee flexion test for sciatic spinal nerve root compression.
In rehabilitation of patients with sciatica, factors prognostic of long-term outcome could prove beneficial in interventions and in evaluating progress toward fitness or capacity for work. In this study results of physical examinations, carried out one year after hospital treatment for suspected lumbar intervertebral disc herniation, were related to outcome after five-years, as assessed by the categorization of occupational handicap of the International Classification of Impairments, Disabilities and Handicaps (ICIDH). The sample consisted of 276 patients admitted to hospital in the years 1980-1982. Based on established clinical indications 179 patients underwent lumbar disc surgery and the remaining 97 received further conservative treatment. One year after hospitalization a physician and physiotherapist examined the patients at the Rehabilitation Research Centre (RRC) of the Social Insurance Institution in Finland. In 1986 the patients returned to the RRC for further evaluation of their occupational handicap at that time. Stepwise logistic regression analysis showed that sensory deficits of legs, tenderness in lumbar extension, decreased repetitive trunk flexion performance (sit-up test), decreased lumbar lordosis and tightness of hamstrings were indicative of a poor outcome in the operated group. For the non-operated patients no statistically acceptable regression analysis model could be established.
BACKGROUND: Variation in expert opinion and lack of a systematic methodology hinder the development of reliable clinical practice guidelines. However standardized protocols have been defined to quantify, combine, and summarize expert judgments. In addition, statistical methods may help to outline guidelines based on simplified models of these judgments. METHODS: To test this hypothesis, stepwise logistic regression (SLR) and classification tree pruning (CTP) were used to predict the results of two expert panels (USA 1992 and Switzerland 1995) on laminectomy in sciatica conditions. Both panels, using the RAND-UCLA explicit method, assessed whether the procedure would be inappropriate or of potential use in 720 case scenarios combining 7 relevant factors. RESULTS: Laminectomy was rated as inappropriate in 60% and 70% of the scenarios by the US and Swiss panels, respectively. Either statistical method, in both panels, based its simplest model on the same 4 factors, as follows: imaging test results; disability; neurological findings; and conservative treatment trials (in decreasing order); the influence of 2 other factors, duration of pain and nerve root irritation, were only marginal. The correct classification rates of the models were 89% and 93% for SLR and 93% and 85% for CTP. Adopting the CTP US algorithm as a guideline would lead to consider performing laminectomy only in patients with imaging evidence of hernia, relatively severe disability, reflex abnormalities, and previous nonsurgical treatment. Adherence to the corresponding CTP Swiss algorithm would result in less restrictive conditions. CONCLUSION: The statistical techniques proved as useful instruments to structure and simplify appropriateness criteria developed by expert panels and to outline parsimonious decision models for clinical practice.
The dynamics of the human spine mark the lumbar disk syndrome and accompanying sciatic complaints as long-standing afflictions of our species. Although Greco-Roman erudition suitably described the ailment, uneven diagnostic and therapeutic acumen confused inquiry for many centuries. Only with the 19th Century advent of improved clinical facilities, pathologic correlation, and active surgical exploration did real insight commence. Not, however, until the 1934 landmark publication of Mixter and Barr was the herniated lumbar disk indicated as a major cause of sciatica. Despite such advances, numerous unresolved issues still surround this disease.