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PubMed2006

A clinical genetic method to identify mechanisms by which pain causes depression and anxiety.

BACKGROUND: Pain patients are often depressed and anxious, and benefit less from psychotropic drugs than pain-free patients. We hypothesize that this partial resistance is due to the unique neurochemical contribution to mood by afferent pain projections through the spino-parabrachial-hypothalamic-amygdalar systems and their projections to other mood-mediating systems. New psychotropic drugs for pain patients might target molecules in such brain systems. We propose a method to prioritize molecular targets by studying polymorphic genes in cohorts of patients undergoing surgical procedures associated with a variable pain relief response. We seek molecules that show a significant statistical interaction between (1) the amount of surgical pain relief, and (2) the alleles of the gene, on depression and anxiety during the first postoperative year. RESULTS: We collected DNA from 280 patients with sciatica due to a lumbar disc herniation, 162 treated surgically and 118 non-surgically, who had been followed for 10 years in the Maine Lumbar Spine Study, a large, prospective, observational study. In patients whose pain was reduced >25% by surgery, symptoms of depression and anxiety, assessed with the SF-36 Mental Health Scale, improved briskly at the first postoperative measurement. In patients with little or no surgical pain reduction, mood scores stayed about the same on average. There was large inter-individual variability at each level of residual pain. Polymorphisms in three pre-specified pain-mood candidate genes, catechol-O-methyl transferase (COMT), serotonin transporter, and brain-derived neurotrophic factor (BDNF) were not associated with late postoperative mood or with a pain-gene interaction on mood. Although the sample size did not provide enough power to persuasively search through a larger number of genes, an exploratory survey of 25 other genes provides illustrations of pain-gene interactions on postoperative mood--the mu opioid receptor for short-term effects of acute sciatica on mood, and the galanin-2 receptor for effects of unrelieved post-discectomy pain on mood one year after surgery. CONCLUSION: Genomic analysis of longitudinal studies of pain, depression, and anxiety in patients undergoing pain-relieving surgery may help to identify molecules through which pain alters mood. Detection of alleles with modest-sized effects will require larger cohorts.

Anxiety Disorders↗

PubMed1981

Delayed sciatic palsy after total hip replacement: case report.

A 33-year-old woman with a 22-year history of juvenile rheumatoid arthritis developed right lower extremity sciatica 32 months after total hip arthroplasty. Physical examination and electromyography localized the abnormality to the sciatic nerve proximal to the midthigh level, involving the branch to the short head of the biceps femoris muscle. At surgical exploration, a sharp spur of methyl methacrylate, used to cement the acetabular prosthesis to the acetabulum, was found to have eroded through the lateral half of the sciatic nerve. The sciatica was relieved by neurolysis. The etiology of sciatic neuropathy after total hip replacement is reviewed.

Adult↗

PubMed1993

A risk/benefit analysis of spinal manipulation therapy for relief of lumbar or cervical pain.

Approximately 12 million Americans undergo spinal manipulation therapy (SMT) every year. Renewed interest in this method requires an analysis of its reported risks and possible benefits. This review describes two patients with spinal cord injuries associated with SMT and establishes the risk/benefit ratios for patients with lumbar or cervical pain. The first case is a man who underwent SMT for recurrent sciatica 4 years after chemonucleolysis. During therapy, he developed bilateral sciatica with urinary hesitancy. After self-referral, myelography demonstrated a total block; he underwent urgent discectomy with an excellent result 3 months after surgery. The second patient with an indwelling Broviac catheter and a history of lumbar osteomyelitis underwent SMT for neck pain. Therapy continued for 3 weeks despite the development of severe quadriparesis. After self-referral, he underwent an urgent anterior cervical decompression and removal of necrotic bone and an epidural abscess with partial neurological recovery. An analysis of these cases and 138 cases reported in the literature demonstrates six risk factors associated with complications of SMT. These include misdiagnosis, failure to recognize the onset or progression of neurological signs or symptoms, improper technique, SMT performed in the presence of a coagulation disorder or herniated nucleus pulposus, and manipulation of the cervical spine. Clinical trials of SMT have been summarized in several recent articles.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1993

Visualisation of symptomatic nerve roots. Prospective study of contrast-enhanced MRI in patients with lumbar disc herniation.

We studied the use of gadolinium diethylenetriaminepentaacetic acid-enhanced MRI in the detection of pathological changes in the nerve roots of 25 patients with unilateral sciatica due to lumbar disc herniation. Enhancement was observed in the affected nerve roots within the root sleeve at the caudal edge of the herniation and was classified into three categories: grade 0, none; grade 1, enhancement restricted to a focal region within the sleeve; and grade 2, diffuse and homogeneous. The grade of enhancement correlated well with the severity of the sciatica, and was considered to be due to a disruption of the blood-nerve barrier, leading to oedema.

Adolescent↗

PubMed2002

Intervertebral discs which cause low back pain secrete high levels of proinflammatory mediators.

Herniated intervertebral disc tissue has been shown to produce a number of proinflammatory mediators and cytokines, but there have been no similar studies using discs from patients with discogenic low back pain. We have compared the levels of production of interleukin-6 (IL-6), interleukin-8 (IL-8) and prostaglandin E2 (PGE2) in disc tissue from patients undergoing discectomy for sciatica (63) with that from patients undergoing fusion for discogenic low back pain (20) using an enzyme-linked immunoabsorbent assay. There was a statistically significant difference between levels of production of IL-6 and IL-8 in the sciatica and low back pain groups (p < 0.006 and p < 0.003, respectively). The high levels of proinflammatory mediator found in disc tissue from patients undergoing fusion suggest that production of proinflammatory mediators within the nucleus pulposus may be a major factor in the genesis of a painful lumbar disc.

Adult↗

PubMed1989

An historical perspective on low back pain and disability.

This review of low back pain and sciatica over the past 3500 years tries to put our present epidemic of low back disability into historical perspective. Backache has affected human beings throughout recorded history (Table 1). What has changed is how it has been understood and managed. Two key ideas in the nineteenth century laid the foundation for our modern approach to backache: that it came from the spine and that it was due to injury. Backache had always previously been considered a rheumatic condition. Only from that time were backache and sciatica considered and treated together. Their management was increasingly dominated by the new orthopedic principle of therapeutic rest. What is new is chronic disability due to simple backache. Apart from rare cases, this only began to appear in the late nineteenth century. It escalated after World War II. It appears to be closely related to changed understanding and management of backache: specifically to the idea that backache is due to serious spinal injury or degeneration and to medical prescription of rest. This is reinforced by the improved social support which makes rest possible. Sadly, we must conclude that much low back disability is iatrogenic.

Back Pain↗

PubMed1993

Postlaminectomy problems with reference to spinal fusion.

Absence of relief of sciatica after laminectomy is not an indication for fusion. Significant remaining low back pain with a distinct morphologic explanation sometimes may be considered an indication for fusion. Recurrent sciatica due to fibrosis is not relieved by fusion. Induced instability because of facetectomy responds well to fusion. Fusion for unspecific remaining complaints after decompressive surgery, not explained by distinct morphologic findings, should be avoided.

Adult↗

PubMed2002

Piriformis syndrome.

Seven patients underwent release of the piriformis from the femur. Patients with residual symptoms after conservative treatment had dramatic relief of sciatica and 70% resumed customary work after surgery. Minimum follow-up was 31 months (average: 51 months). Early diagnosis can avoid prolonging ineffective empiric treatment and disability with satisfactory results achieved in most patients by conservative treatment and relief of sciatica in selected surgical cases.

Adult↗

PubMed1990

Herniated lumbar intervertebral disk.

Low back pain is common, but a herniated intervertebral disk is the cause in only a small percentage of cases. Most symptomatic disk herniations result in clinical manifestations (pain, reflex loss, muscle weakness) that resolve with conservative therapy, and only 5% to 10% of patients require surgery. Sciatica is usually the first clue to disk herniation, but sciatica may be mimicked by other disorders that cause radiating pain. Because more than 95% of lumbar disk herniations occur at the L4-5 or L5-S1 levels, the physical examination should focus on abnormalities of the L5 and S1 nerve roots. Plain radiography is not useful in diagnosing disk herniation, but more sophisticated imaging (myelography, computed tomography, or magnetic resonance imaging) should generally be delayed until a patient is clearly a surgical candidate. Conservative therapy includes nonsteroidal anti-inflammatory drugs, brief bed rest (often for less than 1 week), early progressive ambulation, and reassurance about a favorable prognosis. Muscle relaxants and narcotic analgesics have a limited role, and their use should be strictly time-limited. Conventional traction and corsets are probably ineffective. Except for patients with the cauda equina syndrome, surgery is generally appropriate only when there is a combination of definite disk herniation shown by imaging, a corresponding syndrome of sciatic pain, a corresponding neurologic deficit, and a failure to respond to 6 weeks of conservative therapy.

Back Pain↗

PubMed1996

Patterns of ordering diagnostic tests for patients with acute low back pain. The North Carolina Back Pain Project.

BACKGROUND: Low back pain is a common reason for visiting a physician. Authors of guidelines and insurance payers are currently scrutinizing use of radiography and computed tomography (CT) or magnetic resonance imaging (MRI). OBJECTIVE: To study the determinants of the use of lumbar spine radiography and either CT or MRI in patients with acute low back pain. DESIGN: Prospective cohort study. SETTING: Community-based practices in North Carolina in six strata: urban primary care physicians, rural primary care physicians, urban chiropractors, rural chiropractors, orthopedic surgeons, and practitioners at a group-model health maintenance organization. PATIENTS: 1580 patients with acute low back pain. MEASUREMENTS: Telephone interviews done after the index office visit and at 2, 4, 8, 12, and 24 weeks or until complete recovery; survey of practitioners; and chart abstraction. RESULTS: During the acute back pain episode, 46% of patients had radiography and 9% had CT or MRI. Patient variables related to use of radiography included pain that began more than 2 weeks before the index visit and no previous episodes of low back pain. Practitioner variables associated with use of radiography were being a chiropractor or orthopedic surgeon and having a solo practice. Use of CT or MRI was associated with white race, neurologic deficit at baseline, sciatica, poor functional status at baseline, and small group-practice size. Practitioners' responses to clinical vignettes were associated with aggregate practitioner behavior: In the vignettes and in real life, practitioners were more likely to order CT for patients with sciatica. However, a practitioner's response to a vignette did not predict that practitioner's use of CT or MRI for similar patients in his or her own practice. CONCLUSION: Radiography is commonly used as a diagnostic test for patients with acute back pain. Clinical factors and provider specialty are major correlates of the use of imaging studies.

Acute Disease↗

PubMed1999

Basic and update knowledge of intervertebral disc herniation: review.

Lumbar disc herniation is one of the most common causes of low back pain and/or sciatica. However, the pathogenesis of lumbar disc herniation, low back pain, and sciatica has not been fully understood. Inflammation in nerve root and dorsal root ganglia induced by nucleus pulposus may play an important role in the pathogenesis of spinal pain. I reviewed the basic and update papers regarding lumbar disc herniation. Herniated nucleus pulposus had been considered an enchondroma occurred from intervertebral disc, historically. At present, however, it is emphasized that nucleus pulposus has an inflammatogenic properties to affect the nerve root function, structure, vascular permeability, and pain.

Ganglia, Spinal↗

PubMed2001

Return to work: conducting a worksite assessment.

George is a 46 year old who, at work, develops back pain with right sided sciatica. Initial findings include an absent right ankle jerk with sensory loss in the distribution of the right S1 nerve root. MRI scan confirms the diagnosis of an L5-S1 disc herniation with pressure on the right S1 nerve root. Following referral to a neurosurgeon he undergoes microdiscectomy. He is now six weeks postoperative. The scar healed well. His sciatica and ankle jerk have improved. He is now considering returning to work.

Humans↗

PubMed2003

Lumbar paraspinal muscle function, perception of lumbar position, and postural control in disc herniation-related back pain.

STUDY DESIGN: A follow-up study evaluating postural control, lumbar movement perception, and paraspinal muscle reflexes in disc herniation-related chronic low back pain (LBP) before and after discectomy. OBJECTIVES: To assess the effect of discectomy on postural control, lumbar perception, and reflex activation of paraspinal muscles during sudden upper limb loading. SUMMARY OF BACKGROUND DATA: Impaired muscle function, postural control, and lumbar proprioception have been observed in LBP. However, they have not been studied in sciatica patients after surgery. METHODS: The study included 20 patients selected for an operation for chronic LBP caused by disc herniation and 15 controls without chronic LBP. The paraspinal muscle responses for upper limb loading during unexpected and expected conditions were measured by surface electromyography. The ability to sense lumbar rotation was assessed in a previously validated motorized trunk rotation unit in the seated position. The postural control was measured with a vertical force platform. Pain, disability, and depression scores were recorded. RESULTS: Patients had poorer lumbar perception (P = 0.012) and postural control (P < 0.05) than did healthy controls. The postural control remained unchanged, but lumbar perception (P = 0.054) and the lumbar feed-forward control (P = 0.043) improved after the surgery. CONCLUSIONS: The results demonstrate impaired lumbar proprioception and postural control in sciatica patients. During short-term follow-up after operative treatment, postural control does not seem to change, but impaired lumbar proprioception and feed-forward control of paraspinal muscles seem to recover.

Chronic Disease↗

PubMed2003

Primary and revision lumbar discectomy. A 16-year review from one centre.

We present a review of 553 patients who underwent surgery for intractable sciatica ascribed to prolapsed lumbar intervertebral disc. One surgeon in one institution undertook or supervised all the operations over a period of 16 years. The total number of primary discectomies included in the study was 531, of which 42 subsequently required a second operation for recurrent sciatica, giving a revision rate of 7.9%. Factors associated with reoperation were analysed. A contained disc protrusion was almost three times more likely to need revision surgery, compared with extruded or sequestrated discs. Patients with primary protrusions had a significantly greater straight-leg raise and reduced incidence of positive neurological findings compared with those with extruded or sequestrated discs. These patients should therefore be selected out clinically and treated by a more enthusiastic conservative programme, since they are three times more likely to require revision surgery.

Adolescent↗

PubMed1992

[Sciatic radiculalgia with muscular hypertrophy].

A 52-year-old male developed hypertrophy of the right calf after several bouts of right lumbar pain with sciatica. Electromyography disclosed evidence of demyelination in the territories of the right S1 and S2 roots. Microscopic studies showed both atrophic muscle fibers scattered among fibers of normal caliber and a large number of hypertrophic fibers. Post-sciatica hypertrophy of the calf is a true muscle hypertrophy with muscle weakness. Electromyography may show unusual tracings with repeated complex bursts or continuous activity of motor units. Muscle enzyme levels may be elevated. The size of hypertrophied fibers varies across cases. The cause of the muscle fiber hypertrophy may be either stretching due to the action of antagonists or unusual electrical activity.

Electromyography↗

PubMed1992

Newest knowledge of low back pain. A critical look.

Scientific scrutiny of the low back problem demonstrates its socioeconomic importance in most industrialized societies. Natural history studies reveal that the prognosis for the low back pain patient is excellent; for those with sciatica and painful spondylolisthesis it is good. It is even relatively good for those older patients with symptoms of spinal stenosis. Although today there is a better understanding of pain, the pathomechanism of low back pain is unknown. However, for patients with sciatica, spondylolisthesis, and spinal stenosis, physicians are beginning to get a better perception of what causes the pain. Psychosocial factors, including insurance benefits, have been demonstrated to be more important than biomechanical workload not only for acute but also for chronic low back pain patients who are unable to work. Orthopedic surgeons must recognize this fact when contemplating operations for patients with ill-defined back syndromes. Rarely are diagnoses scientifically valid, nor is the effectiveness of surgery proven by acceptable clinical trials.

Back Pain↗

PubMed1978

Orthopaedic pitfalls.

When presented with an orthopaedic problem, rational management cannot occur without a reasonable diagnosis. Such a diagnosis can only be made by listening to the patient's history, and by examining him with a clear knowledge of important and relevant anatomy. Such relevant anatomy has been outlined in order to make sense of the symptom complexes in: --arm pain --knee pain --back pain without sciatica --back pain with sciatica The behaviour of collagen, which takes three weeks to heal and at least three weeks more to strengthen, is the basis of rational treatment of ligamentous injuries. Advice is given on specific situations to avoid the pitfalls of treatment which is too much, too little, too late or too soon.

Back Pain↗

PubMed1989

Early experience with percutaneous lateral discectomy.

Seventeen patients were treated by percutaneous lumbar discectomy for a herniated disc and sciatica. The criteria for inclusion in this series included: (1) a protruding disc in the lumbar area causing neural compression; (2) persistent sciatica; (3) failure of conservative treatment; (4) magnetic resonance imaging, computer tomographic, or myelographic confirmation of the protrusion; and (5) chronic low-back pain with definite evidence of a protruding disc at the appropriate level. The only contraindication to the procedure is the presence of an extruded fragment. There were ten male and seven female patients, with an average age of 40 years. The operation was performed under local anesthesia and by the method of Hijikata. Six cases were at L5-S1, nine at L4-L5, four at L3-L4, and one at L2-L3. Fourteen of 16 patients were relieved of their symptoms. One operation was aborted due to the inability to pass the cannula beneath arthritic facet joints. One complication occurred early while using general anesthetic. An L5 nerve root was injured, causing a permanent drop foot. Major possible complications include infection, nerve root injury, and vascular injury. The success rate with an average follow-up period of six and one-half months was 87.5%.

Adult↗