Comparison of Lumbar Transforaminal Epidural Dexamethasone and Triamcinolone for Lumbar Radiculopathy

Epidural blockade is becoming one of the most useful and versatile procedures in modern anaesthesiology. What is unique is its application to clinical practice, as it can be placed virtually at any spinal level of vertebral column that allows considerable flexibility. Epidural steroid injections through lumbar transforaminal route to treat pain in lower back where radiculopathy is also associated with, are used widely. It has been reported that these procedures in lumber spine are effective clinically for improved physical function in patients as well as relief of pain of short- and long-term duration. We wanted to determine as to whether there is a difference in the efficacy between nonparticulate (e.g. dexamethasone phosphate) and particulate (e.g. triamcinolone acetate) steroids in Lumbar Epidural via transforaminal approach for acute radicular pain in lumber region and adverse effects of the drugs if any. METHODS66 patients, 33 in each group, with dexamethasone phosphate 8 mg or triamcinolone acetate 40 mg for lumbar transforaminal approach epidural steroid injection, were randomized. Observation was done through visual analog scale, short McGill pain questionnaire, revised Oswestry Disability Index before intervention and a month later. RESULTSA difference which was significant statistically in the visual analog score (2.85 ± 0.83 in group T, 5.76 ± 0.75 in group Dx), McGill Pain Questionnaire (3.73 ± 1.15 in group T, 6.55 ± 0.51 in group Dx) and Oswestry Disability Index (18.67 ± 7.13 in group T, 35.83 ± 5.10 in group Dx ) was found in both but was more in triamcinolone group. CONCLUSIONSEfficacy is more in particulate (triamcinolone) than non-particulate (dexamethasone) in epidural injection through lumbar transforaminal with no drug related complication, performed for radiculopathy in lumbar region.

Comparative study of safety and efficacy of pregabalin and gabapentin in management of neuropathic pain associated with chronic lumbar radiculopathy

Background: Chronic lumbar radiculopathy a clinical condition in which there is back and leg pain associated with sensory, reflex, or motor deficits in the area of nerve root distribution lasting for more than 12 weeks. The prevalence of lumbar radiculopathy has been reported to be 5.3% in men and 3.7% in women. Pregabalin and gabapentin, which fit in to a new category of drugs called as alpha-2-delta (?2?) modulators, have been discovered to be effective in the treatment of neuropathic pain related with multiple conditions. So this study was done to compare safety and efficacy of pregabalin and gabapentin in management of pain associated with chronic lumbar radiculopathy.Methods: This was a randomized two arm comparative prospective study. Total 160 patients were enrolled and randomized equally into 2 groups. Group A patients were given capsule pregabalin 75 mg two times a day orally, Group B patients were given tablet gabapentin 300 mg two times a day. Pain intensity was assessed at the start of study i.e. at baseline (0 week), at 6 weeks and at 12 weeks of starting the treatment using numeric pain rating scale.Results: There was significant reduction in pain at the end of 12 weeks in both the groups (p<0.0001), but there was no significant difference between these two groups. The incidence of adverse effects was also more in group A.Conclusions: Both the drugs are having comparable efficacy but gabapentin is more tolerable in such cases.

Knee Pain Presenting As Lumbar Radiculopathy: A Case Report

Background: Knee pain in general and if to be specific is the pain located anteriorly, and it is widespread among teenage, adults, and the old age population. Among the anterior knee pain etiologies, patellofemoral pain is one of the most common causes of knee pain. One of the significant issues with the patellofemoral pain is that most of the time it is misdiagnosed, or it is underrated for patients' problems, which in the long run lead to severe functional limitations and muscular atrophy. Right clinical diagnosis at an early phase in musculoskeletal conditions is vital. Case summary: The patient presented with chief complaints of diffused pain over right leg tracking it over to the lower back. She presented with a painful limping gait. No tenderness was noted over the lower back; the neural tension test was nonsignificant. Patellar compression test, Clark's test, eccentric step was positive. Severe disuse quadriceps muscular atrophy was noted over-involved limb. Tenderness over the retropatellar surface was significant. The patient was managed with cryotherapy at home, therapeutic ultrasound over the tender area along with Kinesio tapping, proprioception exercises, stretching, and strengthening exercises. Outcome measure: Pain, ROM, girth measurement, gait pattern. Significant improvement was noted in pain on NPS, ROM, and gait pattern in two weeks management. Conclusion: The Physiotherapy management in cases of anterior knee pain, specifically patellofemoral pain, mainly consisting of kinesiotaping, therapeutic ultrasound, cryotherapy, therapeutic exercises are very effective provided right clinical diagnosis, is made. The treatment outcome may be more fruitful if the correct clinical diagnosis is made at an early stage.

Effectiveness Of Intermittent Pelvic Traction With And Without Self Neural Tissue Mobilization In Lumbar Radiculopathy

Background: Low back pain is a very common problem in adults. The clinical application of intermittent pelvic traction has become the common treatment for lumbar radiculopathy and is also used by clinicians in day to day practice. Only few authors have studied about the effectiveness of self neural tissue mobilization during intermittent pelvic traction. Hence the study was undertaken with an intention to find out the effect of intermittent pelvic traction with and without self neural tissue mobilization on pain and functional disability in patients with lumbar radiculopathy. Methodology: 74 patients with lumbar radiculopathy were included in the study. Subjects were randomly divided into two groups. Group A received only IPT and Group B received IPT with SNTM for 20 minutes with 10 second hold and rest time respectively. The treatment was given initially for 6 days continuously thereafter the treatment was given on alternate days for 1 week. Pre and post intervention pain (VAS) and functional disability (ODI) measures were noted. Results: On comparison between pre and post interventional values of pain and functional disability using paired ‘t’ test, a significant difference (p<0.001) were found in both the groups. As well as the present study showed significant decrease in the pain measurement (p=0.023) and functional disability measures (p=0.043) in group treated with IPT with SNTM. Conclusions: This study concluded that both IPT and IPT with SNTM are effective in both pain and functional disability measures. But when both groups were compared with each other, the IPT with SNTM was more effective than that of IPT alone. So it can be chosen as a treatment for lumbar radiculopathy.

Comparative Efficacy of Hip Flexor Muscle Strengthening with Femoral Nerve Stretching and Facet Joint Mobilization for Lumbar Spondylitis

Background: Lumbar Spondylitis (LS) is a common term that denotes degenerative changes that develop in trauma-center patients, specific age groups, and head injury patients. A study done on Indian population reported 60% to 90% of radiological changes of L4 at L5-S1 levels in asymptomatic individuals. These degenerative changes in the lumbar spine may remain asymptomatic or can present as pure axial lumbar pain, lumbar radiculopathy, lumbar myelopathy, or lumbar myeloradiculopathy. So, the aim of the study was to check the effectiveness of hip flexor muscle strengthening, femoral nerve muscle stretching with facet joint mobilization for lumbar spondylitis. Materials and methods: 60 patients were included in the study which was divided into two groups; Group A and Group B, 30 patients in each group. Subjects were randomly selected and assigned to each group. Pre-test measurements of the patient were done with the help of two measures - RolandMorris Low Back Pain and Disability Questionnaire for disability and Visual Analog Scale (VAS). Goniometer was used for range motion of lumbar spine movements done in each group. The Subjects in Group-A were given hip flexor muscles strengthening with femoral nerve stretching for lumbar region for 45 minutes for 4 days in a week for four weeks where the subject were sitting. The Subjects in Group-B were given femoral nerve stretching with facet joint mobilization for 45 minutes for 4 days in a week for four weeks where the subjects were in supine and prone position and remain Sreenivasu Kotagiri, Neeti Mathur, Ashwin Kumar. Comparative Efficacy of Hip Flexor Muscle Strengthening with Femoral Nerve Stretching and Facet Joint Mobilization for Lumbar Spondylitis. IAIM, 2019; 6(9): 49-57. Page 50 relaxed with the feet uncrossed. Result analysis was done by Wilcoxon Sum Rank Test (Mann Whitney U Test). Results: On comparing Group A and Group B for post-treatment VAS score and RMQ score, results showed a significant difference (p=0.001) in improvement in terms of VAS and RMQ. The overall study proved that hip flexor muscle strengthening, femoral nerve stretching with facet joint mobilization for lumbar spondylitis in improving Pain and decreasing the disability level in lumbar radiculopathy and reduce tightness subjects. Conclusion: The analysis obtained indicated that Group B (femoral nerve stretching with facet joint mobilization) showed more significant improvement when compared to Group A ( hip flexor muscles strengthening with femoral nerve stretching).

Mononeuritis Multiplex as the Initial Manifestation of Candida Infective Endocarditis

STUDY DESIGN: Case report. OBJECTIVES: To report a case of mononeuritis multiplex as the initial manifestation of Candida infective endocarditis (IE). SUMMARY OF LITERATURE REVIEW: Mononeuritis multiplex is actually a group of diseases, not a distinct disease entity. It often results from blood vessel diseases, diabetes, or inflammation due to autoimmune connective tissue disorders, although many cases are idiopathic. IE is an infection of the endocardial surface of the heart. Multiple nerves were affected simultaneously in several cases of IE, making consideration of IE important in the differential diagnosis of mononeuritis multiplex. MATERIALS AND METHODS: We present a rare case of a 71-year-old man with IE in whom mononeuritis multiplex was revealed on electromyography; further, he presented with lower back pain and sciatica. RESULTS: The presence of the characteristic symptoms of lumbar radiculopathy in this case delayed the diagnosis and proper treatment of the patient. CONCLUSIONS: Physicians should carefully consider all patient-related data, and also provide accurate information to consultants when they refer patients. This can help to prevent serious complications.

Autologous Conditioned Serum as a Novel Alternative Option in the Treatment of Unilateral Lumbar Radiculopathy: A Prospective Study

STUDY DESIGN: The study was conducted on patients who received autologous conditioned serum (ACS) as a line of treatment at the Orthopedics outpatient department of Post Graduate Institute of Medical Education and Research (PGIMER, Chandigarh) from January 2011 to June 2012. Of the 1,224 patients, 20 males or females were included in the study based on the inclusion and exclusion criteria. The institutional board of PGIMER approved the study before it was initiated. PURPOSE: To study the efficacy of ACS in the treatment of unilateral lumbar radiculopathy. OVERVIEW OF LITERATURE: Interleukin (IL)-1 appears to be of special importance among the cytokines identified in orthopedic diseases. ACS contains high concentrations of IL-1 receptor antagonist, antagonist to IL-1 in that is a biochemical 'sensitizer' of nerve roots in radiculopathy. METHODS: We included 20 patients with unilateral lumbar radiculopathy after obtaining informed consent. We prepared ACS as described by Meijer et al. Under bi-planar fluoroscopic imaging in anterior-posterior and lateral views, ACS was administered via epidural perineural technique. Patients in both groups were evaluated by quadruple visual analogue scale, straight leg raising test, revised Oswestry disability index, and 12-Item Short Form of Health Survey before and after epidural injections at 3 weeks, 3 months, and 6 months. RESULTS: There was a statistically significant change in all parameters from pre-injection to first, second, and third follow-up (p<0.001). CONCLUSIONS: ACS can modify the disease course in addition to reducing pain, disability and improving general health.

Solitary Epidural Lipoma with Ipsilateral Facet Arthritis Causing Lumbar Radiculopathy

A 55-year-old obese man (body mass index, 31.6 kg/m2) presented radiating pain and motor weakness in the left leg. Magnetic resonance imaging showed an epidural mass posterior to the L5 vertebral body, which was isosignal to subcutaneous fat and it asymmetrically compressed the left side of the cauda equina and the exiting left L5 nerve root on the axial T1 weighted images. Severe arthritis of the left facet joint and edema of the bone marrow regarding the left pedicle were also found. As far as we know, there have been no reports concerning a solitary epidural lipoma combined with ipsilateral facet arthorsis causing lumbar radiculopathy. Solitary epidural lipoma with ipsilateral facet arthritis causing lumbar radiculopathy was removed after the failure of conservative treatment. After decompression, the neurologic deficit was relieved. At a 2 year follow-up, motor weakness had completely recovered and the patient was satisfied with the result. We recommend that a solitary epidural lipoma causing neurologic deficit should be excised at the time of diagnosis.

Diagnostic Usefulness of Dermatomal Somatosensory Evoked Potentials by Low Intensity Stimulation in Lumbar Radiculopathy

OBJECTIVE: To investigate diagnostic usefulness of dermatomal somatosensory evoked potentials (DSEP) in the evaluation of lumbar radiculopathy using stimulation intensity lower than conventional stimulation intensity. METHOD: Fifty-seven patients with low back pain were studied with DSEP and needle electromyography (EMG). The radiculopathy was diagnosed by lumbar MRI or operative findings. The DSEP study was performed with stimulation intensity of 1.0x, 1.5x, 2.5x sensory threshold, respectively. We compared the sensitivity and specificity of DSEP and needle EMG in the evaluation of L5 radiculopathy. RESULTS: Radiological and operative findings revealed unilateral herniated disc and L5 root compression in 38 patients (66.7%). Nineteen patients had no significant L5 root compression. The sensitivity and specificity of abnormality were 68.4% and 78.9% in 1.0x sensory threshold stimulation; 71.1%, 78.9% in 1.5x sensory threshold stimulation; and 44.7%, 84.2% in 2.5x sensory threshold stimulation, respectively. Whereas they were 55.2% and 100% in needle EMG. CONCLUSION: DSEP using low stimulus intensity showed higher sensitivity in the diagnosis of L5 radilculopathy, and DSEP might provide additional diagnostic usefulness in the evaluation of patients with suspected L5 radiculopathy.

The Association between Pain Drawings and Electrodiagnostic Findings in Low Back Pain

OBJECTIVE: The purpose of the this study was to determine whether pain location indicated in pain drawings was related to the specific lumbo-sacral radiculopathy. METHOD: The study group consisted of 153 patients (62 men, 91 women) complaining low back pain with or without radiating pain. Nerve conduction study and electromyographic evaluation were performed for the diagnostic purpose. Chi-square test and multivariate stepwise discriminant analysis were used to identify the patients with radiculopathy on the basis of their pain drawings. RESULTS: There was significant relationship between pain location indicated in the pain drawing and the lumbar radiculopathy (p<0.05). In patient without the anterolateral thigh pain, the positivity of S1 radiculopathy was high. In patients with anterolateral thigh and leg pain without posterior thigh pain, the positivity of L5/S1 radiculopathy was high. For predicting the level of the lesion there were three discriminant functions (p<0.05). Patients with S1 radiculopathy showed negative correlation with anterolateral thigh pain. L5/S1 radiculopathy showed negative correlation with posterior thigh pain but were predicted by pain drawing on anterolateral lower leg. CONCLUSION: The results of this study indicate that pain drawings may be helpful in identifying specific radiculopathy. As with any evaluation, the drawings should be considered in combination with findings from other diagnostic methods and interpreted with caution and in light of the full clinical picture.

Thrombolith of the Extradural Vertebral Venous Plexus as a Cause of Lumbar Radiculopathy: A case Report / 대한정형외과학회잡지

Lumbar radiculopathy may occur in the course of many diseases, but abnormalities or pathologic change of extradural vertebral venous plexus is a rare cause of the lumbar radiculopathy. We report a case of lumbar radiculopathy due to thrombolith of the extradural vertebral venous plexus diagnosed by CT and MRI and treated by hemilaminectomy and removal of thrombolith.