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PubMed1996

Classics in Spine. Surgery literature revisited.

STUDY DESIGN: This article reviews the criteria for evaluating the quality of clinical trials. OBJECTIVES: To outline the current methodologic standards by which the validity of controlled trials need to be evaluated. SUMMARY OF BACKGROUND DATA: Weber's study, published in 1983 in Spine, is the only randomized trial comparing surgery and conservative management of sciatica in herniated lumbar discs. METHODS: Weber's article is revisited to illustrate basic principles in the design of clinical trials. RESULTS: Weber's study is a classic in spine surgery and has changed thinking regarding the benefit of surgery in sciatica related to herniated lumbar discs. However, the authors found potentially critical flaws in this study: a large number of crossovers, inadequate sample size, and insensitive outcome measurements. CONCLUSIONS: A randomized, controlled trial is the most rigorous way to evaluate health intervention. Despite the difficulties of performing such studies, investigators should use the most appropriate scientific methodology.

Clinical Trials as Topic↗

PubMed1997

Disorders of the back and spine in construction workers. Prevalence and prognostic value for disability.

STUDY DESIGN: A cohort study on back-related morbidity and its impact on early retirement resulting from disability among employees in the construction industry. OBJECTIVE: To describe the prevalence of back-related morbidity according to different measures in various occupational groups and to assess the prognostic value of these measures for early retirement resulting from disability. METHODS: The results of occupational health examinations conducted in 1986-1988 among 4,958 employees of the German construction industry aged 40-64 years were analyzed. Active follow-up evaluation was carried out between October 1992 and July 1994 to ascertain employment status. RESULTS: Compared with that of white-collar employees, no excess risk for self-reported back pain or sciatica was seen for any of the manual professions. In contrast, the age-adjusted prevalence of clinical findings of the spine was elevated among all employees in manual professions, and the prevalence of a recorded diagnosis related to disorders of the back and spine (ICD-9 position 720-724) was elevated among bricklayers compared with white-collar employees. The relative risk of being granted a disability pension in the follow-up period was 1.6 (95% Confidence Interval [Cl], 1.3-2.1) for persons reporting back pain or sciatica, 1.8 (95% Cl, 1.4-2.2) for persons with an abnormal clinical finding of the spine, and 1.5 (95% Cl, 1.2-1.8) for persons with a recorded medical diagnosis related to disorders of the back or spine (ICD-9 720-724). CONCLUSION: Patterns of morbidity varied according to the evaluated morbidity measure. All three measures qualified as significant predictors of disability and helped to identify high-risk occupations and high-risk employees.

Back Pain↗

PubMed1999

Influence of estrogen-progestin treatment on back pain and disability among slim premenopausal women with low lumbar spine bone mineral density. A 2-year placebo-controlled randomized trial.

STUDY DESIGN: A 2-year randomized controlled trial. OBJECTIVES: To examine the possible preventive or aggravating effect of estrogen-progestin treatment on the back symptoms of slim premenopausal women with low lumbar spine bone mineral density. SUMMARY OF BACKGROUND DATA: The incidence of back pain, sciatica, or both starts to increase clearly among 45-54-year-old Finnish women. METHODS: Forty-eight 39- to 49-year-old premenopausal women with a body mass index of 21 or less and a lumbar spine bone mineral density (L2-L4) of 1.1 +/- 1 g/cm3 or less compared with the normative population were recruited into the study. The women were assigned randomly to receive either estradiol-noretisteron acetate treatment or placebo. Back pain, symptoms, and disability were assessed with the Million and Oswestry questionnaires and pain drawings during the follow-up period at 0, 12, and 24 months. Inquiry also was made concerning previous back pain and sciatica history. RESULTS: There was a statistically significant decrease in nighttime back pain (P < 0.001) and the total Oswestry disability scores (P < 0.004) in the hormone-treated group compared with the control group during the follow-up, but no statistically significant differences were found in daytime back pain. At baseline, the cumulative incidence in a history of pain radiating from the buttock to the foot in this osteopenic study group was 31/48, (64.5%; 95% CI 50.5-78.6), which is much more than the predicted 20/48, (42.4%; 95% CI 39.0-45.7) at this age according to a previous population study. The cumulative incidence of at least one back pain episode 44/48, (91.7%; 95% CI 83.6-99.8) was somewhat higher in these participants than was predicted for a comparative population of women this age, 38/48 (79.2%; 95% CI 70.2-87.3). CONCLUSIONS: It seems that this regimen may have alleviating effects on nighttime back pain and functional back disability in slim osteopenic premenopausal women.

Adult↗

PubMed1999

Activity restrictions after posterior lumbar discectomy. A prospective study of outcomes in 152 cases with no postoperative restrictions.

STUDY DESIGN: A prospective clinical trial was conducted. OBJECTIVES: To determine the feasibility of removing activity restrictions after surgery and encouraging early return to work; to ascertain the clinical and behavioral response to such a strategy; and to identify factors predictive of early return to work, preparatory to possible randomized clinical trials. SUMMARY OF BACKGROUND INFORMATION: Current practice usually entails several weeks to several months of restricted activities after lumbar discectomy to avoid disc "reinjury." Earlier work has suggested these restrictions may not be necessary. METHODS: One hundred fifty-two consecutive working patients undergoing limited open discectomy for herniated lumbar intervertebral disc were treated postoperatively with no activity restrictions. Patients were encouraged to return to full activities as soon as possible. The patients were followed for a minimum of 2 years (average follow-up time = 4.8 years). At follow-up, an independent examiner evaluated each patient and collected further postoperative data. RESULTS: One hundred forty-nine of the 152 patients (98%) returned to work. The average work loss was 1.2 weeks and 148 of 149 patients had returned to full duty by 8 weeks. Approximately one-third of the group returned to work within 1 week of surgery (32%), many the next day. Statistical analysis demonstrated very early return to work did not correlate with either recurrent sciatica, reoperation for reherniation, or ultimate clinical outcome. Seventeen patients (11.2%) had possible reherniations (recurrent sciatica) and eight underwent reoperation (5.3%). CONCLUSION: Lifting of postoperative activity restrictions after limited discectomy allowed shortened time to return to work relative to the 4 to 16 weeks commonly recommended. Complication rates appear comparable to those reported in the literature for patients under postoperative restrictions. Postoperative restrictions may not be necessary in most patients.

Adult↗

PubMed2000

A review of the association between cigarette smoking and the development of nonspecific back pain and related outcomes.

STUDY DESIGN: A structured review of the epidemiologic literature was performed. Thirty-eight studies published in peer-reviewed journals were reviewed. The methodologic strengths and weaknesses of the studies were described and assessed qualitatively. Four studies were excluded because of difficulties in design or interpretation. OBJECTIVES: To provide a systematic analysis of the literature to assess the evidence as to whether smoking is associated with the prevalence and incidence of nonspecific back pain and related outcomes. SUMMARY OF BACKGROUND DATA: Evidence has been gathering regarding the association of smoking with nonspecific back pain and other back disorders, but a comprehensive summary and evaluation of the data have not been published. RESULTS: Positive associations between current smoking and nonspecific back pain were found in 18 of 26 studies in men and 18 of 20 studies in women. For sciatica and herniated discs, there were four of eight and one of five positive studies in men and women, respectively. The majority of these studies were cross-sectional (18 in men and 16 in women), with only a handful of prospective studies. Positive associations between past smoking and nonspecific back pain were reported in five of nine studies in men and five of six studies in women. In addition, increases in the prevalence and/or incidence of nonspecific back pain were found in the majority of studies in which level of consumption was analyzed and reported. An attempt was made to assess whether these results could be artifactual arising from selection bias, confounding bias, publication bias, or errors in measurement. As well, the biologic mechanisms were summarized that have been suggested by various investigators. CONCLUSIONS: The available data are consistent with the notion that smoking is associated with the incidenceand prevalence of nonspecific back pain, but there are too few studies to make any conclusions for the other end points (e.g., sciatica, herniated discs). It cannot be ruled out that the association is a statistical artifact arising from either selection or confounding factors, because the evidence for nonspecific low back pain derives mostly from cross-sectional studies. In addition, it cannot be stated unequivocally that smoking preceded back pain. Long-term follow-up studies are needed to eliminate the possibility that chronic back pain preceded smoking, to better estimate dose-response correlations, and to perform biologic measurements to elucidate possible mechanisms.

Adolescent↗

PubMed2002

Nerve fibers in lumbar spine structures and injured spinal roots express the sensory neuron-specific sodium channels SNS/PN3 and NaN/SNS2.

STUDY DESIGN: This prospective study examined the innervation of lumbar spine in tissues from patients with lower back pain and spine nerve roots from patients with traumatic brachial plexus injuries. OBJECTIVES: To demonstrate the presence of nerve fibers in lumbar spine structures and spine nerve roots, and to determine whether they express the sensory neuron-specific sodium channels SNS/PN3 and NaN/SNS2. SUMMARY OF BACKGROUND DATA: The anatomic and molecular basis of low back pain and sciatica is poorly understood. Previous studies have demonstrated sensory nerves in the facet joint capsule and prolapsed intervertebral disc, but not in the ligamentum flavum. The voltage-gated sodium channels SNS/PN3 and NaN/SNS2 are expressed by sensory neurone that mediate pain, but their presence in the lumbar spine is unknown. METHODS: Tissue samples of ligamentum flavum (n = 32), facet joint capsule (n = 20), intervertebral disc (n = 15), and spine roots (n = 8) were immunostained with specific antibodies to protein gene product 9.5 (a panneuronal marker), SNS/PN3, and NaN/SNS2. RESULTS: Protein gene product 9.5 immunoreactive nerve fibers were detected in 72% of the ligamentum flavum specimens and 70% of the facet joint capsule specimens, but in only 20% of the intervertebral disc specimens. The study detected SNS/PN3- and NaN/SNS2-positive fibers, respectively, in 28% and 3% of the ligamentum flavum specimens and 25% and 15% of the facet joint capsule specimens. Numerous SNS/PN3- and NaN/SNS2-positive fibers were found in the acutely injured spine roots, and some were still present in the dorsal roots in the chronic state. CONCLUSIONS: As the findings showed, SNS/PN3- and NaN/SNS2-immunoreactivity is present in a subset of nerve fibers in lumbar spine structures, including ligamentum flavum, and in injured spine roots. Selective SNS/PN3- and NaN/SNS2-blocking agents may provide new therapy for back pain and sciatica.

Adolescent↗

PubMed2003

Localized venous plexi in the spine simulating prolapse of an intervertebral disc: a report of six cases.

STUDY DESIGN: Six cases are reported in which the clinical presentation of a prolapsed intervertebral disc was found to be caused by a localized venous plexus. OBJECTIVES: To emphasize the fact that the clinical presentation of a localized plexus of epidural veins in the lumbar spine can resemble that of an acute disc prolapse. SUMMARY OF BACKGROUND DATA: The finding of enlarged epidural veins during lumbar disc decompression is relatively common, but it is only recently that they have been implicated as the cause of the presenting symptoms. METHODS AND RESULTS: Six individuals presented with severe pain in the lower back accompanied by sciatica, which had begun acutely. Physical examination in most of these patients showed the presence of neurologic signs in the affected leg. The initial clinical assessment was that of an acute prolapse of a lumbar disc. This diagnosis appeared to be borne out by the MRI scans, which demonstrated a "prolapsed disc" at the relevant level of the spine. However, at surgery, the intervertebral disc appeared to be relatively normal, but at the spine was found a large, localized plexus of epidural veins whose configuration matched the MRI image. The symptoms were relieved by decompression of the spine and ablation of the veins. CONCLUSIONS: Any pathologic process in the lumbar spine compressing a nerve root can cause localized pain in the back accompanied by sciatica. Most of these conditions can be differentiated by means of an MRI scan. The MRI image of a localized plexus of epidural veins, however, closely resembles that of a prolapsed intervertebral disc, which may be diagnostically misleading.

Acute Disease↗

PubMed2006

Lumbar disc herniations: surgical versus nonsurgical treatment.

UNLABELLED: Lumbar disc herniation is among the most common causes of lower-back pain and sciatica. The cause(s) of lumbar disc herniation and the relation of lumbar disc herniation to back pain and sciatica have not been fully elucidated, but most likely comprise a complex combination of mechanical and biologic processes. Furthermore, the natural history of lumbar disc herniation seems generally to be favorable, leaving the optimum treatment for lumbar disc herniation a debate in the literature. Various nonoperative and operative treatment strategies have been tried with varying degrees of success. Treatment often involves patient education, physical therapy, alternative medicine options, and pharmaco-therapy. If these fail, surgical intervention is usually recommended. A literature search was conducted to evaluate the currently known effectiveness of traditional and novel non-operative and surgical techniques for the treatment lumbar disc herniation and to determine if there are substantive new advantages in these newer contemporary treatments or combinations thereof. A structured approach to treatment of a patient who may have a symptomatic lumbar disc herniation is presented, based on analysis of the current literature. No one method of nonoperative or operative treatment would seem definitively to be superior to another. Appropriate multidisciplinary treatment including behavioral analysis and support may offer the hope of improved outcomes for patients with lumbar disc herniation. LEVEL OF EVIDENCE: Level V (expert opinion). See the Guidelines for Authors for a complete description of the levels of evidence.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMed2003

Effects of neutralizing antibodies to tumor necrosis factor-alpha on nucleus pulposus-induced abnormal nociresponses in rat dorsal horn neurons.

STUDY DESIGN: The effect of an anti-tumor necrosis factor alpha (anti-TNFalpha) antibody on abnormal discharges caused by application of nucleus pulposus to the nerve root was investigated in an electrophysiologic study. OBJECTIVES: To assess whether inhibition of TNFalpha can reduce nucleus pulposus-induced abnormal discharges. SUMMARY OF BACKGROUND DATA: It has been shown that TNFalpha, a proinflammatory cytokine, is a key pathogenic factor in the development of nucleus pulposus-induced abnormal discharges as a pain sensation. However, the electrophysiologic mechanisms involved in sciatica after disc herniation still have not been elucidated. METHODS: Extracellular activities of wide-dynamic-range neurons were assessed in 21 rats. Autologous nucleus pulposus harvested from the tail was applied to the L5 nerve root. The animals were simultaneously treated with antibodies to TNFalpha (anti-TNF + nucleus pulposus group) and with phosphate-buffered saline (nucleus pulposus group). As a control (control group), a similar volume of muscle was applied to the nerve root with phosphate-buffered saline. Responses of wide-dynamic-range neurons to noxious and innocuous stimuli were examined for 2 hours. RESULTS: Discharges evoked during noxious stimulation and discharges after withdrawal of stimulation in the nucleus pulposus group were significantly higher than those in the control group (P < 0.05). In the anti-TNF + nucleus pulposus group, discharges after withdrawal of stimulation were remarkably inhibited, as compared with those of the nucleus pulposus group (P < 0.05). However, evoked discharges during stimulation apparently were not inhibited. Responses to innocuous stimulation did not change throughout the measurements. CONCLUSIONS: These data indicate that application of TNFalpha antibodies to the nerve root partially prevents the nucleus pulposus-induced abnormal nociresponses. Therefore, anti-TNFalpha treatment may have a therapeutic effect on sciatica after lumbar disc herniation.

Animals↗

PubMed2005

Low back pain on passive straight leg raising: the anterior theca as a source of pain.

STUDY DESIGN: A prospective clinical and radiologic investigation of two groups of patients presenting with either acute back pain only or acute leg pain only, yet similar restriction in straight leg raising (SLR). OBJECTIVES: To highlight a group of patients presenting with acute low back pain only, yet a restricted SLR normally associated with leg pain (sciatica) caused by a posterolateral disc prolapse. To determine the anatomic source of the pain in the low back pain only group. SUMMARY OF BACKGROUND DATA: A restricted SLR is commonly associated with leg pain (sciatica) due to compression of a nerve root by an intervertebral disc prolapse. Previous studies investigating pain patterns on SLR have suggested that central disc prolapses tend to induce back pain whereas the more lateral prolapses induce leg pain. Such research work has involved patients presenting with typical sciatic pain investigated by myelography and undergoing decompressive surgery. There are no studies specifically investigating patients presenting with low back pain only and reduced SLR. METHODS: Two groups of patients, one with acute low back pain only and one with acute leg pain only, yet showing similar restriction in SLR underwent MR imaging. The scans were reviewed "blind" by an experienced spinal radiologist and imaging features recorded according to a detailed protocol. The MR findings were then compared. RESULTS: Significant disc prolapses were seen equally in both groups. The disc prolapses in the back pain only group were more likely to be central, smaller, to compress the theca only, and to be at a higher lumbar level as compared with the leg pain only group. CONCLUSIONS: Acute low back pain associated with significant restriction in SLR is likely to be caused by a disc prolapse compressing the anterior theca.

Acute Disease↗

PubMed2005

Rates of lumbar disc surgery before and after implementation of multidisciplinary nonsurgical spine clinics.

STUDY DESIGN: Correlation study. OBJECTIVES: To assess the rates of lumbar disc surgery in North Jutland County, Denmark, before and after implementation of two nonsurgical spine clinics, and to compare the observed rates with those for the rest of Denmark in the same time periods. SUMMARY OF BACKGROUND DATA: Few studies have addressed initiatives to reduce high rates of lumbar disc surgery by improving nonsurgical care offered to patients with sciatica and low back pain. METHODS: The study was conducted in North Jutland County, Denmark with 500,000 inhabitants (10% of the Danish population). In 1997, two nonsurgical spine clinics were established, along with an educational program for general practitioners. The clinics targeted patients with sciatica of 1 to 3 months' duration, with or without low back pain. Data on rates of lumbar disc surgery were obtained from the National Registry of Patients. RESULTS: The annual rate of lumbar disc operations for patients in North Jutland County decreased from approximately 60 to 80 per 100,000 before 1997 to 40 per 100,000 in 2001 (P = 0.00), and the rate of elective, first-time disc surgeries decreased by approximately two thirds (P = 0.00). In contrast, the annual rate of lumbar disc operations for patients in the rest of Denmark remained unchanged during the same period. CONCLUSIONS: The implementation of multidisciplinary, nonsurgical spine clinics coincided closely with a significant reduction in the rate of lumbar disc surgery. The observed reduction seems most likely to be causally associated with educational activities and improved patient care provided by the clinics.

Ambulatory Care Facilities↗

PubMed2005

The TRP2 allele of COL9A2 is an age-dependent risk factor for the development and severity of intervertebral disc degeneration.

STUDY DESIGN: Low back pain (LBP) and sciatica are usually caused by degenerative disc disease (DDD). Although they are common, the etiology of these conditions is poorly understood. A large population case-control study in the Southern Chinese was performed to study genetic risk factors to DDD. OBJECTIVES: To gain a better understanding of the etiology of DDD in relation to structural defects of the intervertebral disc. SUMMARY OF BACKGROUND DATA: A Finnish study found an association between LBP and sciatica with two variants of the alpha-chains of collagen IX, encoded by the Trp2 and Trp3 alleles, representing Gln326Trp and Arg103Trp amino acid substitutions in the COL9A2 and COL9A3 genes, respectively. Trp2 was found only in affected individuals (4%), whereas Trp3 was present in both affected (24%) and unaffected (9%) individuals. Because of the low frequency of the Trp2 allele in whites, the significance and contribution of this allele to DDD are not known. Using more objective criteria to define the disease by magnetic resonance imaging (MRI), we tested these alleles for association with DDD in a large population study. METHODS: Lumbar DDD, the presence of anular tears, and disc and endplate herniations were defined by MRI in 804 Southern Chinese volunteers 18 to 55 years of age. These were correlated with the frequencies of the Trp2 and Trp3 alleles. RESULTS: The Trp2 allele was present in 20% of the population and was associated with a fourfold increase in the risk of developing anular tears at 30 to 39 years and a 2.4-fold increase in the risk of developing DDD and endplate herniations at 40 to 49 years. Affected Trp2 individuals had more severe degeneration. The Trp3 allele was absent from the Southern Chinese population. CONCLUSION: This largest-ever population study using MRI to define DDD demonstrates for the first time that the Trp2 allele is a significant risk factor for the development and severity of degeneration. The association is age- dependent as it is more prevalent in some age groups than in others. The contrasting Trp allele frequencies between the Finns and the Chinese are the first indication that the genetic risk factors for DDD varies between ethnic groups.

Adolescent↗

PubMed2006

Paget sarcoma of the spine: Scottish Bone Tumor Registry experience.

STUDY DESIGN: Retrospective case study of 13 cases of Paget sarcoma of the spine accrued from a prospectively collected Tumor Registry database. OBJECTIVES: To analyze the clinical, radiologic, and histologic features of Paget sarcoma of the spine and to determine the factors influencing the prognosis. SUMMARY OF BACKGROUND DATA: Paget disease of bone is a common disorder with the spine being involved in over 50% of patients. However, sarcomatous degeneration in the vertebral column is an extremely rare complication. There is very little in the literature with regard to clinical presentation and prognosis of patients with Paget sarcoma affecting the vertebral column. METHODS: Between January 1944 and December 2003, 89 patients were registered with a diagnosis of Paget sarcoma in the Scottish Bone Tumor Registry. Thirteen patients with Paget sarcoma of the spine were analyzed with regard to their clinical, radiologic, and histopathologic features along with the prognostic predictors. RESULTS: The mean age was 66.9 years (range: 56-79 years). There were 10 males and three females. There were seven cases involving the sacral spine (63.6%), three cases involving lumbar vertebrae, two affecting the dorsal spine, and one with diffuse dorsolumbar involvement (D11-L3). The mode of presentation was progressively increasing low back pain (in all 13), unilateral sciatica (six; left-sided, five; right-sided, one), bilateral sciatica (two), lower limb weakness (eight), and autonomic dysfunction (four). Ten of 13 cases (76.9%) were osteosarcoma. The rest were chondrosarcoma (n = 1), fibrosarcoma (n = 1), and malignant fibrous histiocytoma (n = 1). Decompression laminectomy was performed in three patients with progressive neurologic deficit. Eight patients had received radiotherapy. The mean survival was 4.22 months. CONCLUSIONS: This series confirmed that Paget sarcoma of the spine has a very poor prognosis. We found a constellation of symptomatology in patients with sarcomatous Paget spine resulting from radiculomedullary compression, primarily lumbosacral involvement and predominantly osteosarcomatous histology. There was no significant difference observed on the overall prognosis of the patients with Paget sarcoma of the spine in the last 6 decades.

Adult↗

PubMed2006

Comparison of surgical outcomes between macro discectomy and micro discectomy for lumbar disc herniation: a prospective randomized study with surgery performed by the same spine surgeon.

STUDY DESIGN: A prospective study was conducted on the surgical procedures for lumbar disc herniation. OBJECTIVE: The objective of this study is to investigate the surgical outcomes of different methods when performed by the same surgeon, using a prospective study. BACKGROUND: Macro discectomy is widely known as a common surgical procedure for lumbar disc herniation, while microdiscectomy in place of Caspar technique (the Caspar method) and microendoscopic discectomy by a posterior approach are reported as less invasive surgical methods for this condition. However, there have not been a significant number of prospective studies conducted to compare different surgical procedures for lumbar disc herniation. MATERIALS AND METHODS: The target of our study was a group of 62 patients (male: 43, female: 19) who underwent surgery by macro discectomy (A group) and 57 patients (male: 33, female: 24) who underwent surgery by microdiscectomy in place of Caspar technique (B group). The mean ages at surgery were 34 (14 to 62) years and 41 (18 to 65) years respectively, and the mean duration of follow-up was 2 years and 8 months (12 months to 4 years). For all patients, the surgery was performed by 1 of the authors. The items investigated were the operation time, amount of bleeding, duration of hospitalization, amount of analgesic agent used after surgery, pre- and postoperative scores based on judgment criteria for treatment of lumbar spine disorders established by the Japanese Orthopaedic Association score, visual analog scales (VAS, 0 to 10) for lumbago before surgery and at discharge, VAS for sciatica before surgery and at discharge, perioperative complications, and cases requiring further surgery. RESULTS: There were no significant differences between the 2 surgical procedures in the frequency of use of an analgesic agent after surgery, the pre- and postoperative Japanese Orthopaedic Association scores or postoperative VAS for sciatica. Statistically significant differences were observed in the operation time, amount of bleeding, duration of hospitalization, and postoperative VAS for lumbar pain, but the differences were not large, and may not have been clinically significant. CONCLUSIONS: For herniotomy for lumbar disc herniation, both macro discectomy and microdiscectomy are appropriate, as long as surgeons have mastery of the procedures.

Adolescent↗

PubMed2006

Survey of acute low back pain management by specialty group and practice experience.

OBJECTIVE: The objective of this study was to explore concurrence with evidence-based management of acute back pain by primary care specialty and years in practice groups. METHODS: Participants randomly selected from five American Medical Association physician groups were surveyed asking their initial care recommendations for case scenarios with and without sciatica. Response differences were compared among groups and with the Agency for Health Research Quality's guideline. RESULTS: Response rate was 25%. Emergency physicians were least likely to order diagnostic studies for both cases but more often made recommendations likely to promote inactivity. Occupational physicians were less likely to order diagnostic studies and more likely choose treatments conducive to increasing activity. The longer physicians were in practice, the less likely they were to follow recommendations. All specialty groups selected more nonevidence-based interventions for the patient with sciatica. General practitioners were least likely to follow the guidelines in either case. CONCLUSIONS: Despite widespread dissemination of acute low back pain guidelines, the study suggests a lack of adherence by certain primary care groups, physicians with more practice experience, and in specific areas of management.

Adult↗

PubMed2004

Efficacy of IDET for relief of leg pain associated with discogenic low back pain.

Intradiscal electrothermal annuloplasty (IDET) is an effective treatment for chronic discogenic low back pain (LBP). However, efficacy of IDET for the treatment of referred leg pain has not been examined. This study was performed to assess the long-term efficacy of IDET for the treatment of referred leg pain in chronic discogenic LBP patients. Data were retrospectively analyzed as an IDET case series from January 1999 to December 2000. The IDET procedure was performed at 1-3 symptomatic levels confirmed by pressure-controlled discography. General pain outcome was evaluated by Visual Analog Scale (VAS). LBP and leg pain were assessed separately using five-point pain scales (subsets of the North American Spine Society [NASS] LBP outcome assessment instrument: 0 = no pain, 4 = worst pain) at the 18-month follow-up. Among 129 patients who underwent IDET, 30 patients underwent subsequent back surgery and were excluded from the study, giving a total of 99 patients. Eighty-three patients (83.8%) had leg pain without sciatica. Fifty-two (52.5%), 21 (21.2%), and 8 (8.0%) patients showed LBP > leg pain, LBP = leg pain and LBP < leg pain, respectively. Fifty-three out of 83 patients (63.9%) showed post-IDET improvement in pain, with a mean VAS score of 3.28 +/- 2.31. Thirty patients (36.1%) showed no improvement. A statistically significant (P < 0.05) improvement in subjective back and referred leg pain was observed. Improvements in back and referred leg pain were well-correlated (r = 0.721, P < 0.01). A relatively large number of LBP patients who underwent IDET (84%) presented with referred leg pain without sciatica. The IDET procedure afforded improvements in leg pain that correlated well with improvements in back pain (0.75/4 and 0.88/4, respectively). These data suggest that IDET may relieve associated limb pain in chronic discogenic LBP patients.

Journal Article↗

PubMed1997

Efficacy of non-steroidal anti-inflammatory drugs for low back pain: a systematic review of randomised clinical trials.

PURPOSE: To assess the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) for low back pain. DATA SOURCES: Computer aided search of published randomised clinical trials and assessment of the methods of the studies. STUDY SELECTION: 26 randomised clinical trials evaluating NSAIDs for low back pain were identified. DATA EXTRACTION: Score for quality (maximum = 100 points) of the methods based on four categories: study population; interventions; effect measurement; data presentation and analysis. Determination of success rate per study group and evaluation of different contrasts. Statistical pooling of placebo controlled trials in similar patient groups and using similar outcome measures. RESULTS: The methods scores of the trials ranged from 27 to 83 points. NSAIDs were compared with placebo treatment in 10 studies. The pooled odds ratio in four trials comparing NSAIDs with placebo after one week was 0.53 (95% confidence intervals 0.32 to 0.89) using the fixed effect model, indicating a significant effect in favour of NSAIDs compared with placebo. In nine studies NSAIDs were compared with other (drug) therapies. Of these, only two studies reported better results of NSAIDs compared with paracetamol with and without dextropropoxyphene. In the other trials NSAIDs were not better than the reference treatment. In 11 studies different NSAIDs were compared, of which seven studies reported no differences in effect. CONCLUSIONS: There are flaws in the design of most studies. The pooled odds ratio must be interpreted with caution because the trials at issue, including the high quality trials, did not use identical outcome measures. The results of the 26 randomised trials that have been carried out to date, suggest that NSAIDs might be effective for short-term symptomatic relief in patients with uncomplicated low back pain, but are less effective or ineffective in patients with low back pain with sciatica and patients with sciatica with nerve root symptoms.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMed2003

Radiologic phenotypes in lumbar MR imaging for a gene defect in the COL9A3 gene of type IX collagen.

PURPOSE: To evaluate whether the COL9A3 tryptophan allele (Trp3 allele) is associated with a specific radiologic phenotype among patients with sciatica. MATERIALS AND METHODS: One hundred fifty-three patients with sciatica were evaluated for the presence of Trp3 allele, Scheuermann disease, intervertebral disk degeneration, Schmorl nodules, dorsal anular tears, hyperintense lesions, and endplate degeneration on sagittal T2-weighted lumbar magnetic resonance images. The Trp3 genotype was determined by means of sequencing the COL9A3 gene. Radiologic phenotypes were evaluated while blinded to the genotype. Scheuermann disease was diagnosed if either endplate irregularities or Schmorl nodules and two of the other three criteria (disk space narrowing, disk dehydration, and wedging of anterior vertebral body margins) were present at three or more adjacent disk levels from T10-11 to L3-4. Disk degeneration was evaluated separately for each disk (T11-12 to L5-S1) and for all disks combined. Frequencies of radiologic phenotypes between individuals with or without Trp3 allele were compared. RESULTS: Thirty-four patients had at least one Trp3 allele. When compared with the matched control subjects, they had an increased likelihood of Scheuermann disease (P =.035) and an increased number of degenerated disks from T11 to S1 (P =.021). Comparisons at individual disks showed a statistically significant increase in disk degeneration at T11-12 (analysis of all grades of degeneration [graded], P =.018; analysis of any degeneration vs none [dichotomous], P =.039) and L4-5 (graded, P =.011; dichotomous, P =.016). Prevalences of anular tears, endplate degeneration, Schmorl nodules, and hyperintense lesions were comparable. CONCLUSION: The results of this study indicate that the presence of Trp3 allele is associated with Scheuermann disease and intervertebral disk degeneration. No associations were found for other radiologic phenotypes.

Collagen Type IX↗