Study on mechanism of "Epimedii Folium-Paeoniae Radix Alba" in treatment of lumbar disc herniation based on network pharmacology / 中国中药杂志

The aim of this paper was to investigate the key targets and mechanism of "Epimedii Folium-Paeoniae Radix Alba" in the treatment of lumbar disc herniation by means of network pharmacology. The currently recognized databases and analysis software at home and abroad were used to construct the network from drugs and diseases. The chemical components of Epimedii Folium and Paeo-niae Radix Alba were collected by using databases such as TCMSP, while their active components were determined and the action targets were predicted according to threshold screening and literature reports. The genes for lumbar disc herniation were collected by using GeneCards, OMIM, and DisGeNET databases. The drug targets were mapped to disease targets, and protein interaction network analysis for key targets, GO function enrichment analysis and KEGG signaling pathway enrichment analysis were performed. Finally, 23 active components of Epimedium Folium and 13 active components of Paeoniae Radix Alba were determined, and a total of 624 drug targets were obtained. After standardization, 214 drug targets were obtained. In addition, 306, 2 and 5 related targets of lumbar disc herniation were collected from GeneCards, OMIM, and DisGeNET database, respectively, and a total of 293 disease targets were obtained after deduplication. After the mapping of drug target and disease target, 44 common targets were obtained. PPI protein interaction network analysis showed that IL-6, TNF, AKT1, MAPK1, and VEGFA may be the core targets for the treatment of lumbar disc herniation. GO enrichment analysis identified 56 items(P<0.05), among which biological processes mainly included immune response, apoptosis, etc.; cell components mainly included extracellular space, extracellular region, etc.; molecular functions mainly included cytokine activity, metallopeptidase activity and so on. Through KEGG pathway enrichment analysis, 91 signaling pathways related to inflammation, metabolism, and senescence were identified, mainly including IL-17 signaling pathway and TNF signaling pathway and so on. "Epimedii Folium-Paeoniae Radix Alba" showed the characteristics of multi-channel and multi-target for the treatment of lumbar disc herniation. This study preliminarily explored the key targets for its role and the biological processes and signaling pathways involved. It was found that it may play a therapeutic role by affecting inflammation and immune regulation, which laid the foundation for further experimental verification.

Efficacy and safety of Shentong Zhuyu Decoction for lumbar disc herniation: systematic review and Meta-analysis / 中国中药杂志

To evaluate the clinical efficacy and safety of Shentong Zhuyu Decoction in the treatment of lumbar disc herniation, in order to provide evidence for its clinical application. PubMed, Cochrane Library, EMbase, CNKI, WanFang, VIP, CBM and Clinical Trials.gov databases were sysmatically retrieved. Two researchers independently searched, screened and extracted data. Randomized controlled trials in line with the inclusion criteria were included in the study. The article quality was assessed with the bias risk tool in the Cochrane Handbook. Meta-analysis was performed using RevMan 5.3. A total of 604 articles were obtained from the retrieval, and 824 patients in 9 studies were finally selected through screening. The course of treatment was about 1 month, and all of the studies were completed in China. Meta-analysis showed that the efficacy of Shentong Zhuyu Decoction in the treatment of lumbar disc herniation was better than that of the control group(RR=1.19, 95%CI[1.12, 1.26], P<0.000 01), including the comparison with Yaotongning Capsules(RR=1.10, 95%CI[1.02, 1.19], P=0.01) and diclofenac sodium tablets(RR=1.26, 95%CI[1.11, 1.44], P=0.000 4). In VAS pain score, Shentong Zhuyu Decoction had also obvious advantages(MD=-3.70, 95%CI[-6.31,-1.09], P=0.005). In addition, the number of adverse events in the Shentong Zhuyu Decoction group was lower than that in the control group. Shentong Zhuyu Decoction can effectively alleviate discomfort symptoms of patients with LDH. It has an obvious clinical efficacy and less adverse reactions. However, restricted by the quality of the included literatures, prospective, multi-center, large-sample-size randomized controlled trials are still needed to further improve the clinical evidence of the effect of Shentong Zhuyu Decoction in the treatment of LDH.

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)

Results of treatment of acute lumbar disc herniation with transforaminal nerve root block / Resultados do tratamento da hérnia discal lombar aguda com bloqueio anestésico transforaminal / Resultados del tratamiento de la hernia discal lumbar con bloqueo anestésico transforaminal

ABSTRACT Objective: To determine the efficacy of anesthetic transforaminal nerve root block in patients with sciatica secondary to lumbar disc herniation through a prospective observational study. Methods: The study included 176 patients from a private clinic undergoing transforaminal injection performed by a single spinal surgeon. The patients were assessed after two weeks, three months and six months regarding to the improvement of the pain radiating to the lower limbs. In case of persistent symptoms, patients could choose to perform a new nerve root block and maintenance of physical therapy or be submitted to conventional microdiscectomy. Results: By the end of six-month follow-up of the 176 patients, 116 had a favorable outcome (95 after one block and 21 after two blocks), and only 43 required surgery. Conclusion: The results of our study suggest a positive effect of transforaminal block for the treatment of sciatica in patients with lumbar disc herniation.

RESUMO Objetivo: Determinar a eficácia do bloqueio anestésico transforaminal nos pacientes com ciática secundária à hérnia de disco lombar, por meio de um estudo prospectivo observacional. Métodos: Foram incluídos no estudo 176 pacientes de uma clínica privada submetidos à injeção transforaminal executada por um único cirurgião de coluna. Os pacientes foram reavaliados após duas semanas, três meses e seis meses quanto à melhora da dor irradiada para os membros inferiores. Na persistência dos sintomas, os pacientes poderiam optar por realizar um novo bloqueio e manutenção da fisioterapia ou serem submetidos à microdiscectomia convencional. Resultados: No final do seguimento de seis meses dos 176 pacientes, 116 apresentaram evolução satisfatória (95 após um bloqueio e 21 após dois bloqueios) e apenas 43 necessitaram da cirurgia. Conclusão: Os resultados do nosso estudo sugerem um efeito positivo do bloqueio transforaminal para o tratamento da ciatalgia nos pacientes com hérnia de disco lombar.

RESUMEN Objetivo: Determinar la eficacia del bloqueo anestésico transforaminal en pacientes con dolor radicular secundario a hernia de disco lumbar, a través de un estudio prospectivo observacional. Métodos: El estudio fue compuesto por 176 pacientes de una clínica privada sometidos al bloqueo anestésico transforaminal realizado por un único cirujano de la columna. Los pacientes fueron re-evaluados al cabo de dos semanas, tres meses y seis meses con respecto a la mejora del dolor que se irradia a las extremidades inferiores. En caso de persistencia de los síntomas los pacientes podrían optar por realizar un nuevo bloqueo anestésico y mantenimiento de fisioterapia o someterse a una microdiscectomía convencional. Resultados: Al final del seguimiento de seis meses de los 176 pacientes, 116 tuvieron resultado favorable (95 luego de sólo un bloqueo y 21 después de dos bloqueos) y en solamente 43 pacientes la cirugía fue necesaria. Conclusión: Los resultados de nuestro estudio sugieren un efecto positivo del bloqueo anestésico transforaminal para el tratamiento de la ciática en los pacientes con hernia de disco lumbar.

Cervical Interlaminar Epidural Steroid Injection for Unilateral Cervical Radiculopathy: Comparison of Midline and Paramedian Approaches for Efficacy

OBJECTIVE: The objective of this study was to compare the clinical outcomes of the cervical interlaminar epidural steroid injection (CIESI) for unilateral radiculopathy by the midline or paramedian approaches and to determine the prognostic factors of CIESI. MATERIALS AND METHODS: We retrospectively analyzed 182 patients who underwent CIESI from January 2009 to December 2012. Inclusion criteria were no previous spinal steroid injection, presence of a cross-sectional image, and presence of follow-up records. Exclusion criteria were patients with bilateral cervical radiculopathy and/or dominant cervical axial pain, combined peripheral neuropathy, and previous cervical spine surgery. Short-term clinical outcomes were evaluated at the first follow-up after CIESI. We compared the clinical outcomes between the midline and paramedian approaches. Possible prognostic factors for the outcome, such as age, gender, duration of radiculopathy, and cause of radiculopathy were also analyzed. RESULTS: Cervical interlaminar epidural steroid injections were effective in 124 of 182 patients (68.1%) at the first follow-up. There was no significant difference in the clinical outcomes of CIESI, between midline (69.6%) and paramedian (63.7%) approaches (p = 0.723). Cause of radiculopathy was the only significant factor affecting the efficacy of CIESI. Patients with disc herniation had significantly better results than patients with neural foraminal stenosis (82.9% vs. 56.0%) (p < 0.001). CONCLUSION: There is no significant difference in treatment efficacy between the midline and paramedian approaches in CIESI, for unilateral radiculopathy. The cause of the radiculopathy is significantly associated with the treatment efficacy; patients with disc herniation experience better pain relief than those with neural foraminal stenosis.

Tratamento farmacológico da hiperalgesia experimentalmente induzida pelo núcleo pulposo / Pharmacologic treatment of hyperalgesia experimentally induced by nucleus pulposus

OBJETIVO: Avaliar o efeito de drogas anti-inflamatórias (dexametasona, indometacina, atenolol, indometacina e atenolol) e analgésica (morfina) sobre a hiperalgesia experimentalmente induzida pelo núcleo pulposo em contato com o gânglio da raiz dorsal de L5. MÉTODOS: Trinta ratos Wistar machos com peso de 220 a 250g foram utilizados no estudo. A indução da hiperalgesia foi realizada por meio do contato de fragmento de núcleo pulposo retirado da região sacrococcígea e colocado sobre o gânglio da raiz dorsal de L5. Os 30 animais foram divididos em grupos experimentais de acordo com a droga utilizada. As drogas foram administradas durante duas semanas a partir da realização do procedimento cirúrgico para a indução da hiperalgesia. A hiperalgesia mecânica e térmica foram avaliadas por meio do teste da pressão constante da pata, von Frey eletrônico e Hargraves por um período de sete semanas. RESULTADOS: A maior redução da hiperalgesia foi observada no grupo de animais tratados pela morfina, seguido pela dexametasona, indometacina e atenolol. A redução da hiperalgesia foi observada após a interrupção da administração das drogas, com exceção do grupo de animais tratados com morfina, nos quais ocorreu aumento da hiperalgesia após a interrupção do tratamento. CONCLUSÕES: A hiperalgesia induzida pelo contato do núcleo pulposo com o gânglio da raiz dorsal pode ser reduzida com a administração de anti-inflamatórios e analgésicos, tendo sido observado a maior redução da hiperalgesia com a administração da morfina e dexametasona.

OBJECTIVE: To evaluate the effect of antiinflammatory (dexamethasone, indomethacin, atenolol, indomethacin and atenolol) and analgesic drugs (morphine) on hyperalgesia experimentally induced by nucleus pulposus (NP) contact with the L5- dorsal root ganglion (DRG). METHODS: Thirty male Wistar rats with weights ranging from 220 to 250 g were used in the study. The hyperalgesia was induced by contact of a fragment of NP removed from the sacrococcygeal region and placed on the dorsal root ganglion of L5. The 30 animals were divided into experimental groups according to the drug administered. The drugs were administered during the two weeks after the surgical procedure to induce hyperalgesia. Mechanical and thermal hyperalgesia was evaluated by the paw pressure test, von Frey electronic test, and the Hargraves test, for a period of seven weeks. RESULTS: The greatest reduction of hyperalgesia was observed in animals treated by morphine and dexamethasone, followed by dexamethasone, indomethacin, and atenolol. The reduction of hyperalgesia was observed after drug administration ceased, except for animals treated with morphine, in which there was an increased hyperalgesia after cessation of treatment. CONCLUSION: Hyperalgesia induced by NP contact with L5-DRG can be reduced by administration of antiinflammatory and analgesic drugs, but there was a greater reduction observed with the administration of dexamethasone and indometacin.

Citocinas pró-inflamatórias em pacientes com dor neuropática submetidos a tratamento com Tramadol / Proinflammatory cytokines in patients with neuropathic pain treated with Tramadol / Interleucinas proinflamatorias en pacientes con dolor neuropático sometidos a tratamiento con Tramadol

JUSTIFICATIVA E OBJETIVOS: As citocinas pró-inflamatórias têm função importante na fisiopatologia das síndromes dolorosas neuropáticas. O objetivo desse estudo foi avaliar os níveis plasmáticos de citocinas pró-inflamatórias antes e após o tratamentocom tramadol em pacientes com hérnia discal e síndrome do túnel do carpo e compará-los com indivíduos normais.MÉTODO: Investigou-se 38 pacientes com dor neuropática por hérnia discal ou síndrome do túnel do carpo. Todos os pacientes foram tratados com tramadol de liberação controlada (100 mg em 12h) durante 10 dias. Realizaram-se coletas de sangue venoso (5 mL), no período matutino, antes do tratamento e no 11º dia e as amostras foram armazenadas até análise (-70ºC). Foram utilizados testes enzimáticos ELISA para dosagem de citocinas plasmáticas (TNF-α, IL-1, IL-6) e receptores sTNF-R1, (R & D Systems). Realizou-se dosagem de citocinas em soro de 10 voluntários sadios. RESULTADOS: A concentração de TNF-α antes (5,8 ± 2,8 pg.mL-1) foi significativamente maior que após o tramadol (4,8 ± 2,1 pg.mL-1; p = 0,04, Teste Mann-Whitney). Não houve diferença significativa de IL-1β, IL-6 e sTNF-R1 antes e após o tratamento. As concentrações plasmáticas de TNF-α (sadios: 1,4 ± 0,5; pacientes com dor: 5,8 ± 2,8 pg.mL-1; p = 0.01) e IL-6 (sadios: 1,2 ± 0,8; pacientes com dor: 3,5 ± 2,6 pg.mL-1; p = 0,01) foram significativamente maiores nos pacientes com dor neuropática que nos voluntários, Teste de Mann-Whitney. CONCLUSÕES: Nos pacientes com hérnia discal e síndrome do túnel do carpo as concentrações plasmáticas de TNF-α e IL-6 foram maiores que em voluntários sadios, não havendo diferença das concentrações de sTNF-R e IL-1β. Houve redução da concentraçãoplasmática de TNF-α após tratamento com tramadol (100 mg em 12h), mas não de IL-6, sTNF-R e IL-1β.

BACKGROUND AND METHODS: Proinflammatory cytokines play an important role in the pathophysiology of neuropathic pain syndromes. The objective of this study was to evaluate plasma levels of proinflammatory cytokines before and after treatment with tramadol in patients with herniated intervertebral disks and carpal tunnel syndrome, and to compare them with normal individuals. METHODS: Thirty-eight patients with neuropathic pain secondary to herniated intervertebral disks or carpal tunnel syndrome participated in this study. All patients were treated with controlled release tramadol (100 mg every 12 hours) for 10 days. Venous blood (5 mL) was collected in the morning, before treatment and on the 11th day, and stored (-70º C) until analysis. ELISA was used to determine the plasma levels of cytokines (TNF-α, IL-1, IL-6) andreceptors sTNF-R1 (R & D Systems). Plasma levels of cytokines of 10 healthy volunteers were also determined. RESULTS: The concentration of TNF-α before (5.8 ± 2.8 pg.mL-1) was significantly higher than after treatment with tramadol (4.8 ± 2.1 pg.mL-1; p = 0.04, Mann-Whitney test). The levels of IL-1β, IL-6, and sTNF-R1 before and after treatment with tramadol showed nosignificant differences. Plasma levels of TNF-α (healthy individuals: 1.4 ± 0.5; pain patients: 5.8 ± 2.8 pg.mL-1; p = 0.01) and IL-6 (healthy individuals: 1.2 ± 0.8; pain patients: 3.5 ± 2.6 pg.mL-1; p = 0.01) were significantly higher in patients with neuropathic pain, Mann-Whitney Test. CONCLUSIONS: In patients with herniated intervertebral disks and carpal tunnel syndrome, plasma levels of TNF-α and IL-6 werehigher than in healthy volunteers, while differences in the concentrations of sTNF-R and IL-1β were not observed. Plasma levels of TNF-α, but not of IL-6, sTNF-R, and IL-1β, decreased after treatment with tramadol (100 mg every 12 hours).

JUSTIFICATIVA Y OBJETIVOS: Las interleucinas proinflamatorias tienen una función importante en la fisiopatología de los síndromes dolorosos neuropáticos. El objetivo de este estudio, fue evaluar los niveles plasmáticos de interleucinas proinflamatorias antes y después del tratamiento con tramadol en pacientes con hernia de disco y síndromedel túnel del carpo, y compararlos con individuos normales. MÉTODO: Se investigaron 38 pacientes con dolor neuropático por hernia de disco o síndrome del túnel del carpo. Todos los pacientes fueron tratados con tramadol de liberación controlada (100 mg en 12h) durante 10 días. Se realizaron muestras de sangre venosa (5 mL), por la mañana, antes del tratamiento y en el 11º día, y las mismas se almacenaron para ser analizadas (-70ºC). Se utilizaron test enzimáticos ELISA para la dosificación de las interleucinas plasmáticas (TNF-α, IL-1, IL-6) y receptores sTNFR1, (R & D Systems). Se realizó la dosificación de interleucinasen suero de 10 voluntarios sanos. RESULTADOS: La concentración de TNF-α antes (5,8 ± 2,8 pg.mL-1) fue significativamente mayor que después del tramadol (4,8 ± 2,1 pg.mL-1; p = 0,04, Test de Mann-Whitney). No hubo diferencia significativa de IL-1β, IL-6 y sTNF-R1 antes y después del tratamiento. Las concentraciones plasmáticas de TNF-α (sanos: 1,4 ± 0,5; pacientes con dolor: 5,8 ± 2,8 pg.mL-1; p = 0.01) y IL-6 (sanos: 1,2 ± 0,8; pacientes con dolor: 3.5 ± 2,6 pg.mL-1; p = 0,01) fueron significativamente mayores en los pacientes con dolor neuropático que en los voluntarios, test de Mann-Whitney. CONCLUSIONES: En los pacientes con hernia discal y síndrome del túnel del carpo, las concentraciones plasmáticas de TNF-α yIL-6, fueron más elevadas que en los voluntarios sanos, no habiendo ninguna diferencia en las concentraciones de sTNF-R y IL-1β...

Chemonucleolysis in lumbar disc herniation: a meta-analysis

PURPOSE: To carry out a systematic review and meta-analysis of the efficacy of chemonucleolysis in the treatment of lumbar disc herniation. METHODS: Clinical trials were selected from 3 electronic databases (The Cochrane Controlled Trials Register, MEDLINE, and EMBASE). Data were analyzed with the software STATA, using the meta command. RESULTS: Twenty-two clinical trials were eligible. For chemonucleolysis versus placebo, the summary risk ratio estimate for pain relief as outcome was 1.51 (95 percent CI: 1.27-1.80). The summary estimate was 1.07 (95 percent CI: 0.95-1.20) for the comparison between chymopapain and collagenase. Regarding chemonucleolysis with chymopapain versus surgery, the fixed-effect summary estimate of effect for pain relief was 0.93 (95 percent CI: 0.88-0.98) with surgery as the reference group. In this case, heterogeneity was statistically significant. CONCLUSIONS: Chemonucleolysis with chymopapain was superior to placebo and was as effective as collagenase in the treatment of lumbar disc prolapse. Results for studies comparing chemonucleolysis with surgery were heterogeneous, making it difficult to interpret the summary measure of effect.

OBJETIVO: Avaliar a eficácia da quimonucleólise no tratamento da hérnia de disco lombar por meio de uma metanálise de ensaios clínicos. MÉTODOS: Os ensaios clínicos foram selecionados de três bases de dados eletrônicas( Cochrane, MEDLINE, e EMBASE). Os dados foram analisados por intermédio do aplicativo STATA, com o comando meta. RESULTADOS: trabalhamos com 22 ensaios clínicos. Para a comparação entre quimonucleólise e placebo, a estimativa da razão de riscos, tendo melhora da dor como desfecho, foi de 1,51 (I 95 por cento C: 1,27-1,80). Aquela medida foi de 1,07 (I 95 por cento C: 0,95-1,20) para a comparação entre quimopapaína e colagenase. Em um modelo de efeitos fixos, a razão de risco, para melhora da dor, foi 0,93 (I 95 por cento C: 0,88-0,98), tendo a discectomia como grupo de referência. Nesse caso, um teste de heterogeneidade foi considerado estatisticamente significante. CONCLUSÕES: a eficácia da quimonucleólise foi superior à do placebo e semelhante à da colagenase. Os resultados dos estudos referentes à comparação entre quimonucleólise e cirurgia foram heterogêneos, o que implica interpretação não-trivial da medida de efeito.

The Use of Magnetic Resonance Imaging to Predict the Clinical Outcome of Non-Surgical Treatment for Lumbar Interverterbal Disc Herniation

OBJECTIVE: We wanted to investigate the relationship between the magnetic resonance (MR) findings and the clinical outcome after treatment with non-surgical transforaminal epidural steroid injections (ESI) for lumbar herniated intervertebral disc (HIVD) patients. MATERIALS AND METHODS: Transforaminal ESI were performed in 91 patients (50 males and 41 females, age range: 13-78 yrs) because of lumbosacral HIVD from March 2001 to August 2002. Sixty eight patients whose MRIs and clinical follow-ups were available were included in this study. The medical charts were retrospectively reviewed and the patients were divided into two groups; the successful (responders, n = 41) and unsatisfactory (non-responders, n = 27) outcome groups. A successful outcome required a patient satisfaction score greater than two and a pain reduction score greater than 50%. The MR findings were retrospectively analyzed and compared between the two groups with regard to the type (protrusion, extrusion or sequestration), hydration (the T2 signal intensity), location (central, right/left central, subarticular, foraminal or extraforaminal), and size (volume) of the HIVD, the grade of nerve root compression (grade 1 abutment, 2 displacement and 3 entrapment), and an association with spinal stenosis. RESULTS: There was no significant difference between the responders and non-responders in terms of the type, hydration and size of the HIVD, or an association with spinal stenosis (p > 0.05). However, the location of the HIVD and the grade of nerve root compression were different between the two groups (p < 0.05). CONCLUSION: MRI could play an important role in predicting the clinical outcome of non-surgical transforaminal ESI treatment for patients with lumbar HIVD.

Síndrome de hiperinfección por Strongyloides stercolaris / Syndrome of hiperinfection for Strongyloides stercolaris

Se describe un paciente de 43 años, costarricense, con tratamiento de una hernia discal por varios meses con esteroides, anti-infamatorios no esteroideos (AINES) y antihistaminicos (anti-H2), quien desarrolla un síndrome de hiperinfección por Strongyloides a nivel gástrico e intestinal, acompañándose de bacteremia por bacilos gram negativos y compromiso sistémico, resolviendo luego de terapia intensiva y multidisciplinaria.

Sciatica y quimionucleólisis / Sciatica and chemonucleolysis

En casos de sciatica debido a un disco herniado lumbar, la quimionucleólisis nos provee con un método de tratamiento eficaz y seguro en aquellos casos en los cuales ha fallado el tratamiento conservador. Mediante una selección meticulosa y una técnica quirúrgica precisa los resultados a obtener serán magníficos. Este estudio consta de setenta y siete pacientes con disco herniado lumbar que fueron tratados con quimopapaína intradiscal. Todos eran candidatos para tratamiento con cirugía abierta. Ochenta y ocho porciento de los pacientes obtuvieron resultados excelentes o buenos sin ninguna complicación. Aunque aparenta sencillo, este tratamiento requiere atención al detalle de diagnóstico y técnica quirúrgica

Discos intervertebrales lumbares extruidos / Extruded lumbar disks

La discolisis percutanea con colagenasa produce resultados altamente satisfactorios en pacientes con discos lumbares protruidos, pero no actua cuando el disco esta extruido, caso en el cual esta indicada la excision quirurgica del tejido herniado. Con el objeto de establecer este diagnostico diferencial se hizo el estudio retrospectivo de las historias clinicas y las mielografias de los archivos del Instituto Neurologico de Colombia. El cuadro clinico clasico de dolor lombociatico continuo producico por el disco extruido no aliviado con reposo en cama, con signos de compresion radicular fue observado en 10 a 30 casos seleccionados de discos extruidos. En 19 enfermos la mielografia fue concluyente. Al combinar los hallazgos clinicos y mielograficos se pudo establecer el diagnostico con certeza en solo dos terceras partes de los casos. En esta serie no se utilizo la discografia, procedimiento que podria ser adicionado para incrementar nuestra capacidad de distinguir los discos lumbares extruidos de los protruidos.