Infiltraciones epidurales de esteroides en el tratamiento del dolor radicular en el contexto laboral / Infiltrations épidurales de stéroïdes pour le traitement de la douleur radiculaire dans un contexte de travail / Epidural Infiltration of Steroids in the Treatment of Root Pain in the Occupation Context

Introducción : el dolor ciático es un tipo de dolor en la extremidad inferior que normalmente sigue una distribución metamérica específica. A menudo es causado por una compresión o irritación del nervio ciático, comúnmente debido a hernia discal lumbar. Es uno de los motivos más habituales de consulta en unidades de cirugía de columna vertebral. Objetivo: determinar si las infiltraciones epidurales de esteroides pueden mejorar los síntomas en pacientes con una hernia discal, y así evitar la cirugía, lo que les permite una pronta vuelta al trabajo. Método: se reclutaron 71 pacientes con hernia discal, con historia de dolor ciático de al menos 3 meses de duración. Los pacientes recibieron un máximo de 3 infiltraciones epidurales de esteroides administradas con 2 semanas de separación, seguidas por un programa de rehabilitación. Resultados: de los 71 pacientes, 71,8 por ciento presentaron hernia discal en L5-S1, 87 por ciento eran hombres, edad media de 40,2 años y un 57,7 por ciento tenían trabajos asociados con altas demandas funcionales. El promedio de semanas de baja laboral fue 16,63. Al año, el 63,4 por ciento de los pacientes fueron dados de baja y un 36,6 por ciento requirió cirugía debido a la persistencia del dolor a pesar del tratamiento con inyecciones epidurales de esteroides. El índice de discapacidad de Oswestry y la puntuación EVA reflejaron una mejoría estadísticamente significativa (p < 0,001) después de las infiltraciones en la mayoría de los casos. Conclusiones: en nuestro contexto, la administración de infiltraciones esteroides epidurales en pacientes con dolor radicular secundario con hernia discal es un procedimiento mínimamente invasivo y efectivo que alivia el dolor, reduce la discapacidad y permite un rápido retorno a la actividad laboral(AU)

Introduction: Sciatic pain is a type of pain in the lower extremity that usually follows a specific metameric distribution. The compression or irritation of the sciatic nerve is often the cause, commonly due to lumbar disc herniation. It is one of the most common reasons for consultation in spinal surgery units. Objective: Determine if epidural steroid infiltrations can improve symptoms in patients with a herniated disc, thus avoiding surgery, which allows them to return to work soon. Method: We recruited 71 patients with a herniated disc, with a history of sciatic pain of at least 3 months. Patients received a maximum of three epidural infiltrations of steroids given 2 weeks apart, followed by a rehabilitation program. Results: Out of the 71 patients, 71.8 percent had L5-S1 disc hernia, 87 percent were men, mean age was 40.2 years and 57.7 percent had jobs associated with high functional demands. The average number of weeks off from work was 16.63. At one year, 63.4 percent of patients were discharged and 36.6 percent required surgery because of persistent pain despite treatment with epidural steroid injections. The Oswestry disability index and Visual Analog Scale (VAS) reflected a statistically significant improvement (p <0.001) after infiltrations in most cases. Conclusions: In our context, the administration of epidural steroid infiltrations in patients with secondary radicular pain with a herniated disc is a minimally invasive and effective procedure that alleviates pain, reduces disability and allows a quick return to work activity(AU)

Introduction: La douleur sciatique est une sorte de douleur localisée aux membres inférieurs suivant généralement une distribution métamérique spécifique. Elle est en général causée par une compression ou irritation du nerf sciatique, surtout due à une hernie discale lombaire. Elle est l'une des causes les plus fréquentes de consultation aux services de chirurgie de colonne vertébrale. Objectif: Définir si les infiltrations épidurales de stéroïdes peuvent soulager les symptômes chez les patients atteints d'hernie discale et éviter ainsi la chirurgie, leur permettant un prompt retour au travail. Méthodes: Soixante-onze patients atteints d'hernie discale et avec une histoire de douleur sciatique d'au moins 3 mois de durée ont été inclus dans cette étude. Les patients ont subi un maximum de 3 infiltrations épidurales de stéroïdes, administrées avec 2 semaines d'intervalle, et suivies d'un programme de rééducation. Résultats: Sur 71 patients, la plupart souffrait d'une hernie discale en L5-S1 (71,8 pourtent), était du sexe masculin (87 pourtent), âgée de 40,2 ans en moyenne, et avec des occupations d'une grande charge fonctionnelle (57,7 pourtent). L'arrêt de travail pour maladie a eu une durée de 16,63 semaines en moyenne. Au bout d'un an, la majorité des patients (63,4 pourtent) ont été licenciés, et une minorité (36,6 pourtent) a eu besoin d'une chirurgie, malgré les injections épidurales de stéroïdes (douleur persistante). Dans la plupart des cas, l'évaluation de l'incapacité fonctionnelle (questionnaire d'Oswestry) et l'échelle d'auto-évaluation de la douleur (score EVA) ont montré une amélioration statistiquement significative (p < 0.001) après les infiltrations épidurales de stéroïdes. Conclusion: Dans notre contexte, l'administration d'infiltrations épidurales de stéroïdes chez des patients ayant une douleur radiculaire secondaire et une hernie discale est un procédé peu invasif mais effectif, soulageant la douleur, réduisant l'incapacité, et permettant un retour rapide aux activités de travail(AU)

Sinal de cecin (sinal "X"): um aprimoramento no diagnóstico de compressão radicular por hérnias discais lombares / Cecina signal (signal "X"): an improvement in the diagnosis of nerve root compression by herniated lumbar disc

O autor, ao reiterar que o exame clínico continua sendo o pilar do exercício da medicina, propôs, anteriormente, uma nova manobra semiótica, o sinal "X" ou de Cecin, para aprimorar o diagnóstico da hérnia de disco lombar, e descreveu seus fundamentos biomecânicos. Entretanto, o desempenho diagnóstico dessa manobra ainda não foi formalmente avaliado. PACIENTES E MÉTODOS: A manobra semiótica - Sinal de Cecin -, que consiste na flexão da coluna lombar e na realização simultânea da manobra de Valsalva, foi aplicada em 45 pacientes com lombociatalgia típica e herniação discal correspondente confirmada pela ressonância magnética (RM), e em 21 pacientes com lombalgia mecânica comum, sem ciatalgia e com RM normal. O sinal de Lasègue foi testado concomitantemente e a discordância e concordância entre as duas manobras foram avaliadas. RESULTADOS: Foi observada uma alta discrepância (P < 0,001) e baixa concordância (P < 0,4) entre os dois testes. O sinal de Cecin teve sensibilidade de 73,3 por cento e 95,2 por cento de especificidade para o diagnóstico das hérnias discais confirmadas pela RM. Na mesma amostragem, o sinal de Lasègue apresentou sensibilidade de 22,2 por cento e especificidade de 95,2 por cento (P < 0,001), valor preditivo positivo de 90,9 por cento e negativo de 36,4 por cento (P = 0,153). CONCLUSÃO: O sinal de Cecin apresentou melhor desempenho diagnóstico do que o de Lasègue para o diagnóstico de hérnia discal lombar sintomática.

While reaffirming that the clinical exam still is the best medical practice, the author has proposed a new maneuver (Cecin's sign or "X" sign) to help the diagnosis of herniated lumbar disk, describing its biomechanical bases. However, the diagnostic performance of this maneuver has not been formally tested. PATIENTS AND METHODS: The maneuver, which consists on the flexion of the lumbar spine while simultaneously performing the Valsalva maneuver, was tested in 45 patients with typical sciatic pain and herniated lumbar disk confirmed by magnetic resonance imaging (MRI), and in 21 patients with simple mechanical back pain with normal MRI. Lasègue's sign was investigated concomitantly and the concordance with the "X" sign was assessed. RESULTS: Concordance between the two tests was very low (Kappa = 0.17, Kappa <0.4) and discordance was statically significant (P <0.001). The "X" sign had a sensitivity of 73.3 percent, specificity of 95.2 percent, positive predictive level of 97.1 percent, and negative predictive level of 62.5 percent in the diagnosis of herniated lumbar disk by MRI, while Lasègue's sign showed sensitivity of 22.2 percent, specificity of 95.2 percent (P <0.001), positive predictive value of 90.9 percent, and negative predictive value of 36.4 percent (P = 0.153). CONCLUSION: Cecin's sign had higher sensitivity, positive predictive value, and negative predictive value than Lasègue's sign in the diagnosis of symptomatic herniated lumbar disk.

Sciatic Pain Caused by Piriformis Syndrome / 대한정형외과학회잡지

PURPOSE: Sciatic pain rarely develops from piriformis syndrome; thus, its differential diagnosis from other diseases associated with sciatic pain is essential. We analysed the clinical symptoms and radiological findings for the differential diagnosis of piriformis syndrome, and assessed the results of its treatment. MATERIALS AND METHODS: We analysed five patients diagnosed with piriformis syndrome. Four patients were treated with a tenotomy. Of these, three had a history of misdiagnosis. The hypertrophied piriformis muscle was revealed with a compressed sciatic nerve in the operative field. We performed a tenotomy of the piriformis at the site of the tendinous insertion to decompress the sciatic nerve. RESULTS: At the average follow up was 23.5 months, at which time no patients had any problems relating to tenderness and sciatic pain, and were able to return to normal activity one month postoperatively. All patients evaluated their postoperative clinical state as being better. CONCLUSION: Multiple approaches are essential for the diagnosis of piriformis syndrome. We can obtain the satisfactory results through a tenotomy of the piriformis for the decompression of the sciatic nerve in intractable cases as a conservative treatment.