The combined effect of neuro-modulation and neuro-stimulation on pain in patients with cervical radiculopathy - a double-blinded, two-arm parallel randomized controlled trial.

INTRODUCTION: Cervical radiculopathy is one of those disabling conditions which results in central and peripheral pain and thus affects the quality of life. Transcutaneous Electrical Nerve Stimulation (TENS) and exercises produce analgesic effect but their long-term effect has not been available to date. Transcranial Direct Current stimulation (tDCS) is known to produce promising effects on central pain by targeting cortical activity. PURPOSE: To determine the combined effect of tDCS and TENS with exercises on pain and quality of life in patients with cervical radiculopathy. METHOD: Forty four patients (male: female = 26:18) of the age group 18-50 years were recruited and randomly allocated into the experimental group and control group. The experimental group received active anodal tDCS for 20 min with an intensity of 2 mA, while the control group received sham anodal tDCS. TENS over the pain distribution area for 20 min with 5 Hz intensity and 80-150 ms pulse duration followed by neck-specific exercises were given in both groups. This protocol was given 5 days a week for 4 weeks. Pre and post-assessments were obtained through outcome measures that the Numeric Pain Rating Scale and Neck Disability Index for the measurement of pain, functional disability, and quality of life. RESULT: Paired t-test/Wilcoxon-Signed Rank test, and Index and Mann-Whitney U test were used to compare the demographic variables within and across the groups, respectively for Neck Disability for Numeric Pain Rating Scale, keeping the P-value < 0.05 as significant. One-way repeated-measures analysis of variance (ANOVA) was applied to determine the between-subject factor differences. Post hoc tests with Bonferroni correction for repeated analyses were performed. Results depicted a significant effect for NDI (P = 0.001 for both groups) and NPRS (P = 0.003 for the experimental group and 0.007 for the control group). Significant Interaction effect (time*group) was observed for NDI (F = 42, 5382.77) and NPRS (F = 42, 1844.57) with a P-value of 0.001 for both outcome measures. Clinical significance was observed for both outcome measures having a mean difference in 50.21 and 4.57 for NDI and NPRS, respectively compared with the established MCID of 13.2 and 2.2 scores for respective outcome measures. CONCLUSION: It was concluded that active tDCS along with TENS and exercise intervention was effective on pain, disability, and quality of life in patients with cervical radiculopathy.

Predictive Factors Associated with Chronic Neck Pain in Patients with Cervical Degenerative Disease: A Retrospective Cohort Study.

Purpose: To explore the predictive factors of neck pain (NP) in patients with cervical degenerative disease by retrospectively analyzing their occupational and demographic characteristics and to provide a valuable reference for preventing and treating chronic NP. Patients and Methods: We retrospectively reviewed the occupational and demographic data of patients with cervical degenerative disease who had undergone anterior cervical surgery between June 2021 and December 2022 at our center. The patients were divided into NP and no-NP groups based on whether they had chronic NP before surgery. Relevant occupational and demographic data from all patients were statistically analyzed, and all variables were made categorical. Forward stepwise logistic regression models were constructed for preoperative chronic neck pain to explore the possible risk factors associated with chronic neck pain. Results: The differences in smoking, being an office worker, BMI, and disease types between NP and no-NP groups were statistically significant. In contrast, there were no statistically significant in age, sex, academic level, duration, and degeneration grade between the two groups. Moreover, further logistic regression analysis indicated that smoking, being an office worker, having an abnormal BMI, and cervical spondylotic radiculopathy (CSR) were related to chronic neck pain. Conclusion: The present study indicated that smoking, being an office worker, having an abnormal BMI, and CSR were predisposing risk factors for NP associated with cervical degenerative disease. Although intervertebral disc degeneration is the pathology basis of NP, the degeneration grade was not related to the occurrence of NP in our current study. Therefore, quitting smoking, avoiding sedentariness, and maintaining a normal BMI may prevent NP to some extent.

Imaging Findings, Fluoroscopic Time, and Results of the Lumbosacral Selective Nerve Root Block: Focus on the L5 Nerve Root Block.

Introduction Selective nerve root block (SNRB) is a valuable diagnostic and therapeutic tool. In some cases, intra-nerve root puncture is difficult and time-consuming, and radiation exposure time for the surgeon may be prolonged. The aim of this study is to examine the contrast findings, fluoroscopic time, and outcomes of SNRB. Methods A total of 139 cases of SNRB were included in the study. We investigated radiating pain presence, duration of fluoroscopic time, contrast types for nerve roots, and SNRB outcomes. Contrast patterns of nerve roots were categorized into three types, which were: type 1: the presence of contrast along the nerve roots; type 2: the presence of contrast within the intravertebral foramen but not in the nerve root; and type 3: the absence of both nerve root and intravertebral foramen contrast. Results The mean fluoroscopic time was 12.8 ± 15.3 seconds for type 1, 11.1 ± 8.9 seconds for type 2, and 23.6 ± 18.8 seconds for type 3. Statistically significant differences were found between the three groups (p = 0.007), and subsequent multiple comparisons showed significant differences between type 1 and type 2 (p = 0.010) and between type 2 and type 3 (p = 0.015). The visual analog scale (VAS) score before and 30 minutes after SNRB demonstrated a significant improvement in all patients. The mean change in VAS before and after nerve root block was 49.6 ± 21.7 mm for type 1 cases, 49.8 ± 25.2 mm for type 2 cases, and 37.8 ± 23.6 mm for type 3 cases, with no statistically significant difference between the three groups (p = 0.090). The proportion of patients with subjective symptomatic improvement before and after SNRB was 91.3% in type 1 cases, 88.5% in type 2 cases, and 85.7% in type 3 cases, with no statistically significant difference between the three groups (p = 0.641). Conclusions The above findings indicate that type 3 is beneficial for both diagnostic and therapeutic purposes.

Disseminated Zoster Involving the Whole Body in an Immunocompetent Patient Complaining of Left Leg Radiating Pain and Weakness: A Case Report and Literature Review.

Introduction: Disseminated herpes zoster is defined as at least 20 skin lesions in multiple dermatomes. In particular, it has been reported mainly in patients with immunological defects. To our knowledge, there is no reported case of disseminated zoster in a non-immunocompromised patient with leg radiating pain and weakness. Case presentation: A 74-year-old man visited our hospital with left leg radiating pain and left hip pain. He had no underlying disease other than hypertension. Neurologic examination revealed radiating pain on the L4 dermatome of the left leg. The muscle power was grade 3 for the hip flexor and knee extensor, and grade 4 for the ankle dorsiflexor and big toe dorsiflexor of the left leg. There were no sensory changes or skin lesions on his left leg. Herniation of the nucleus pulposus of the lumbar spine was suspected and lumbar magnetic resonance imaging (MRI) was performed. However, no pathologic lesions were seen on lumbar MRI. On the third day of hospitalization, erythematous patches and vesicles were observed on the head, face, ear, neck, trunk, back, and both lower extremities. Herpes zoster infection was confirmed by polymerase chain reaction analysis. Treatment was performed with 250 mg of intravenous acyclovir every 8 hours for 6 days and 62.5 mg of intravenous methylprednisolone for 4 days. On the 13th day of hospitalization, the skin lesions and left leg radiating pain and weakness improved. Conclusion: We report the first case of disseminated herpes zoster involving the whole body in a non-immunocompromised patient complaining of left leg radiating pain and weakness. After treatment, both the patient's radiating pain and weakness improved.

Influence of Tensioner's Mobilization on the Centralization of Symptoms in Cervicobrachial Pain Syndrome: A Randomized Controlled Trial.

STUDY DESIGN: This study was designed as a randomized controlled trial. PURPOSE: The present study aimed to determine the impact of neural mobilization by tensioner's technique (NMTT) on the centralization of symptoms and pain in patients with cervicobrachial pain syndrome (CBPS). OVERVIEW OF LITERATURE: CBPS is a disabling condition of the neck that is characterized by pain and paresthesia in the upper quarter. Several techniques have successfully provided immediate and long-term relief in CBPS; however, few studies have evaluated the effect of these techniques on the centralization of symptoms. METHODS: Thirty patients aged 18-45 years with a complaint of pain in the neck that had persisted for 2-12 weeks radiating to the arm and fulfilling Elvey's criteria were randomly selected and divided into two groups. Group A received NMTT plus conventional treatment (hot pack and postural advice with cervical lateral glide), and group B received only conventional treatment 3 times a week for 2 weeks. The outcome measures were Wernicke's scale score for the centralization of symptoms and Visual Analog Scale score for pain intensity. Within- and between-group comparisons were made before initiating treatment and at the end of the 3rd and 6th sessions. Within group analyses for the centralization values were performed using Friedmann test, and between-group analyses were performed using Mann-Whitney test. A 2×3 mixed model of the analysis of variance was used for analyzing the pain levels. RESULTS: There was a significant difference (p<0.05) within and between the groups for both the measures at the end of the 3rd and 6th sessions. Thus, NMTT may be beneficial in decreasing the peripheralization of symptoms and pain intensity in patients with CBPS. CONCLUSIONS: NMTT can be used as an alternative and effective treatment option for patients with CBPS.

The substantial clinical benefit of comprehensively considering low back pain and radiating pain caused by lumbar intervertebral disc herniation.

BACKGROUND: Patients with lumbar disc herniation (LDH) may experience low back pain (LBP) and radiating pain (RP). Currently, there is no substantial clinical benefit (SCB) of assessing both LBP and RP due to LDH. OBJECTIVE: To determine enhanced SCB values by simultaneously assessing LBP and RP. METHODS: We retrospectively evaluated hospitalized LDH patients with concomitant LBP and RP between June 1, 2012, and May 31, 2013, and determined the numeric rating scale (NRS) and Oswestry Disability Index (ODI) scores at admission and discharge. Furthermore, the area under the receiver operating characteristic curve (AUC) was computed to assess diagnostic accuracy. RESULTS: SCB as per NRS for both LBP and RP was -2.50 in the 186 enrolled patients (AUC: 0.699 and 0.704, respectively). SCB as per ODI was -18.78 (AUC: 0.771). SCB for the mean of the two NRS scores for LBP and RP was -2.75 (AUC: 0.757). SCB for NRS score with a larger change in LBP and RP was -3.50 (AUC: 0.767). CONCLUSIONS: SCB may be determined by comprehensively considering LBP and RP and choosing the mean NRS or NRS score with a large change.

Comparison of Effect and Contrast Spreading in Transforaminal Epidural Injection Using the Retrodiscal Versus Subpedicular Approach: A Prospective, Randomized Trial.

BACKGROUND: Lumbar transforaminal epidural injection (TFEI) effectively decreases low back pain and radicular pain in herniated intervertebral disc (HIVD) and spinal stenosis (SS). The precise delivery of drugs to the target is important for pain control and minimizing complications. OBJECTIVES: We aimed to evaluate the efficacy and complications of the subpedicular (SP) and retrodiscal (RD) approaches by analysis of contrast spread patterns into the pathologic target on the basis of a newly established specific criterion. We also investigated whether the severity of patients' spinal disease influenced this pattern. STUDY DESIGN: A prospective, randomized, observational study. SETTING: Interventional pain management center at a university-affiliated hospital. METHODS: Among patients who showed lumbar spinal stenosis or HIVD at the L4/5 level, participants were randomly assigned to undergo TFEI with the SP approach (SP group) or RD approach (RD group). Pain relief in terms of the visual analog scale (VAS) score and complications such as intravascular or intradiscal uptake were also analyzed. The contrast image was analyzed as the contrast media was injected, starting from 0.5 mL up to 3.0 mL. The spread patterns of contrast media were graded into 4 categories, which were newly defined in this study. RESULTS: Both groups demonstrated a significant decrease in pain relief (P value < 0.01) at 2 and 4 weeks after the procedures, but no significant difference was found between the 2 groups. In the intergroup analysis between the RD and SP groups, with a 1.5-mL contrast media injection, more patients in the RD group (17.2%) showed a grade 3 spread than those in the SP group (8.2%). In the subgroup analysis, the RD group showed superior spread (more grade 3 and 4) with 1.5-, 2-, and 2.5-mL contrast media injections (P values = 0.02, 0.03, and 0.04) in severe central stenosis, and 1.5- and 2-mL contrast media injections (P values = 0.01, 0.02) in severe foraminal stenosis. LIMITATIONS: The follow-up period was only 4 weeks after TFESI, and higher contrast injection was used for procedures. CONCLUSIONS: The RD approach for TFEI showed a better contrast spreading pattern than the SP approach, especially in patients with severe central and foraminal spinal stenosis. The RD approach might be more beneficial for patients with severe central and foraminal spinal stenosis in the short-term follow-up.

A rare case of acute meningitis shortly after lumbar selective nerve root block: a case report.

A 57-year-old man underwent lumbar selective nerve root block (SNRB) for low back pain and lower radiating pain caused by left-sided L4 disc herniation. He presented to the emergency department with fever, headache and aggravated low back pain approximately 3 hours after the procedure. Infection was suspected; hence, blood tests, cerebrospinal fluid (CSF) tests, lumbar magnetic resonance imaging, and brain computed tomography were performed. Imaging findings were not suggestive of infection. The CSF was turbid and yellowish with pleiocytosis; however, the CSF culture was negative. Based on these findings, the patient was diagnosed with acute meningitis. Broad-spectrum antibiotics and steroid therapy were initiated considering the patient's age and general condition. From hospital day (HD) 2, fever and headache were reduced and disappeared completely by HD 5. At the last follow-up, 1 month after discharge, the patient had no symptoms. Acute meningitis is associated with a high mortality and neurologic deficits. Hence, timely tests, diagnosis, and treatment are critical for positive outcomes. Symptoms of meningitis following a nerve block generally occur within 24-48 hours after the procedure. This case is notable, as it involved a quicker and more sudden onset of symptoms; meningitis occurred only a few hours after lumbar selective nerve root block.

Radiating pain during epidural needle insertion and catheter placement cannot be associated with postoperative persistent paresthesia: a retrospective review.

BACKGROUND: It has been suggested that radiating pain during spinal or epidural needle insertion and catheter placement can be an indicator of needle-related nerve injury. In this study, using a historical cohort, we investigated what factors could be associated with postoperative persistent paresthesia. In addition, we focused on radiating pain during epidural needle insertion and catheterization. METHODS: This was a retrospective review of an institutional registry containing 21,606 anesthesia cases. We conducted multivariate logistic analysis in 2736 patients, who underwent epidural anesthesia, using the incidence of postoperative persistent paresthesia as a dependent variable and other covariates, including items of the anesthesia registry and the postoperative questionnaire, as independent variables in order to investigate the factors that were significantly associated with the risk of persistent paresthesia. RESULTS: One hundred and seventy-six patients (6.44%) were found to have persistent paresthesia. Multivariate analysis revealed that surgical site at the extremities (odds ratio (OR), 12.5; 95% confidence interval (CI), 2.77-56.4; the reference was set at abdominal surgery), duration of general anesthesia (per 10 min) (OR, 1.02; 95% CI, 1.01-1.03), postoperative headache (OR, 1.78; 95% CI, 1.04-2.95), and days taken to visit the consultation clinic (OR, 1.03; 95% CI, 1.01-1.06) were independently associated with persistent paresthesia. Radiating pain was not significantly associated with persistent paresthesia (OR, 1.56; 95% CI, 0.69-3.54). CONCLUSION: Radiating pain during epidural procedure was not statistically significantly associated with persistent paresthesia, which may imply that this radiating pain worked as a warning of nerve injury.

Upper Lumbar Intradural Disc Herniation: A Rare Case Report and Etiologic Analysis.

BACKGROUND: Intradural disc herniation (IDH) is a rare type of disc degeneration that infrequently affects the upper lumbar spine. Pre- and intraoperative diagnosis and surgical management of IDH are challenging. The present case study provides insight into these aspects of upper lumbar IDH and discusses possible mechanisms. CASE DESCRIPTION: A 63-year-old female with a history of chronic lower back and leg pain presented with an acute lumbar sprain that had occurred 1 month prior. The pain progressed and spread to the front of the left thigh, which affected her ability to lift her leg when ascending/descending stairs. Sagittal gadolinium-enhanced magnetic resonance imaging (MRI) revealed a disc protruding into the ventral dural sac showing a hawk-beak sign, and the posterior edge of the disc annulus and local posterior longitudinal ligament was broken. Total L2 laminectomy was performed, and the dorsal side of the dural sac was exposed and incised to enable exploration of the ventral side of the dura. We found two free fragments protruding into the inner wall of the dura through the left ventral dura mater defect. After carefully and completely removing the mass, we repaired the defect and performed internal fixation. Postoperative pathologic analysis confirmed that the mass was nucleus pulposus tissue from the degenerated disc. The patient's pain significantly improved after surgery, and she was able to walk normally at the 1-month follow-up. CONCLUSION: Upper lumbar IDH is an extremely rare type of disc degeneration. An enhanced MRI scan can provide diagnostic evidence, but the final diagnosis requires surgical exploration of the path of herniation and pathologic examination of the mass lesion.

Vertical traction for lumbar radiculopathy: a systematic review.

BACKGROUND: Only low-quality evidence is currently available to support the effectiveness of different traction modalities in the treatment of lumbar radiculopathy (LR). Yet, traction is still very commonly used in clinical practice. Some authors have suggested that the subgroup of patients presenting signs and symptoms of nerve root compression and unresponsive to movements centralizing symptoms may benefit from lumbar traction. The aim of this study is to conduct a systematic review of randomized controlled trials (RCTs) on the effects of vertical traction (VT) on pain and activity limitation in patients affected by LR. METHODS: We searched the Cochrane Controlled Trials Register, PubMed, CINAHL, Scopus, ISI Web of Science and PEDro from their inception to March 31, 2019 to retrieve RCTs on adults with LR using VT to reduce pain and activity limitation. We considered only trials reporting complete data on outcomes. Two reviewers selected the studies, extracted the results, and performed the quality assessment using the Risk of Bias and GRADE tools. RESULTS: Three studies met the inclusion criteria. Meta-analysis was not possible due to the heterogeneity of the included studies. We found very low quality evidence for a large effect of VT added to bed rest when compared to bed rest alone (g = - 1.01; 95% CI = -2.00 to - 0.02). Similarly, VT added to medication may have a large effect on pain relief when compared to medication alone (g = - 1.13; 95% CI = -1.72 to - 0.54, low quality evidence). Effects of VT added to physical therapy on pain relief were very small when compared to physical therapy without VT (g = - 0.14; 95% CI = -1.03 to 0.76, low quality evidence). All reported effects concerned short-term effect up to 3 months post-intervention. CONCLUSIONS: With respect to short-term effects, VT may have a positive effect on pain relief if added to medication or bed rest. Long-term effects of VT are currently unknown. Future higher quality research is very likely to have an important impact on our confidence in the estimate of effect and may change these conclusions.

Severe Atrophy of the Ipsilateral Psoas Muscle Associated with Hip Osteoarthritis and Spinal Stenosis-A Case Report.

Pathology of the lumbar spine and hip joint can commonly coexist in the elderly. Anterior and lateral leg pain as symptoms of hip osteoarthritis and spinal stenosis can closely resemble each other, with only subtle differences in both history and physical examinations. It is not easy to identify the origin of this kind of hip pain. The possibility of hip osteoarthritis should not be underestimated, as this could lead to an incorrect diagnosis and inappropriate spinal surgery. We report the case of a 54-year-old female with chronic right anterior and lateral leg pain who did not respond to repeated spinal blocks based on lumbar MRI, but in whom hip osteoarthritis was considered since severe atrophy of the ipsilateral psoas muscle was identified. We suggest that severe psoas muscle atrophy can be a clinical clue to identify hip osteoarthritis and is related to lower extremity pain, even if there is a coexisting lumbar spine pathology.

Effectiveness of Mechanical Traction for Lumbar Radiculopathy: A Systematic Review and Meta-Analysis.

OBJECTIVE: Lumbar radiculopathy (LR) is a pain syndrome caused by compression/irritation of the lumbar nerve root(s). Traction is a well-known and commonly used conservative treatment for LR, although its effectiveness is disputed. The purpose of this systematic review and meta-analysis of randomized controlled trials was to evaluate the effects of different types of traction added to or compared with conservative treatments on pain and disability. METHODS: Data were obtained from CENTRAL, PUBMED, CINAHL, Scopus, ISI Web of Science, and PEDro from their inception to April 2020. All randomized controlled trials on adults with LR, using mechanical traction, and without any restriction regarding publication time or language were considered. Two reviewers selected the studies, evaluated the quality assessment, and extracted the results. Meta-analysis used a random-effects model. Eight studies met the inclusion criteria, and 5 were meta-analyzed. RESULTS: Meta-analyses of results from low-quality studies indicated that supine mechanical traction added to physical therapist treatments had significant effects on pain (g = -0.58 [95% confidence interval = -0.87 to -0.29]) and disability (g = -0.78 [95% confidence interval = -1.45 to -0.11]). Analyses of results from high-quality studies of prone mechanical traction added to physical therapist intervention for pain and disability were not significant. These results were also evident at short-term follow-up (up to 3 months after intervention). CONCLUSION: The literature suggests that, for pain and disability in LR, there is short-term effectiveness of supine mechanical traction when added to physical therapist intervention. IMPACT: This systematic review may be relevant for clinical practice due to its external validity because the treatments and the outcome measures are very similar to those commonly used in a clinical context.

Spurling's test - inconsistencies in clinical practice.

Objective: The purpose of this study was to investigate the methodology, interpretation, and perceived value of Spurling's test toward diagnosis/classification and treatment. Methods: An anonymous web-based survey was made available to physical therapist members of the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Based on video demonstrations of technique and symptom distribution, questions included preferred method, criteria for test interpretation, and perceived value of Spurling's test and other examination findings toward clinical decision-making. Professional profile data were also collected. Results: Among the 452 participants completing the survey, no method of testing was preferred by more than 37%, with ipsilateral lateral flexion, rotation, and extension with compression being most frequently preferred followed by ipsilateral lateral flexion with compression at 32%. Proximal provocation of symptoms only without distal symptoms was interpreted as a positive test by 67%. Participants rated Spurling's test of moderate to low value toward diagnosis/classification and treatment. Discussion: Inconsistency with methodology and interpretation of Spurling's test is suggested to be pervasive in physical therapist practice. While an optimal test methodology has yet to be identified, result interpretation does have a basis for clarification toward diagnosis/classification and reduction of unwanted variance in practice.

Prolonged pain reducing effect of sodium hyaluronate-carboxymethyl cellulose solution in the selective nerve root block (SNRB) of lumbar radiculopathy: a prospective, double-blind, randomized controlled clinical trial.

BACKGROUND: The pattern of linear graph schematized by visual analogue scale (VAS) score displaying pain worsening between 2 days and 2 weeks after selective nerve root block (SNRB) is called rebound pain. PURPOSE: The purpose of this study was to determine if sodium hyaluronate and carboxymethyl cellulose solution (HA-CMC sol) injection could reduce the occurrence of rebound pain at 3 days to 2 weeks after SNRB in patients with radiculopathy compared with injection with corticosteroids and local anesthetics alone. STUDY DESIGN/SETTING: Double blinded randomized controlled clinical trial. PATIENT SAMPLE: A total of 44 patients (23 of 24 patients in the Guardix group and 21 of 24 patients in the control group) who finished the follow-up session were subjects of this study. OUTCOME MEASUREMENT: Patients were asked to write down their average VAS pain scores daily for 12 weeks. Functional outcomes were assessed by Oswestry Disability Index, Roland Morris Disability Questionnaire , and Short Form-36. METHOD: A cocktail of corticosteroids, 1% lidocaine, 0.5% Bupivacaine, and 1 mL of normal saline was used for the control group whereas a cocktail of corticosteroids, 1% lidocaine, 0.5% Bupivacaine, and 1 mL of HA-CMC solution was used for the G group. Study participants were randomized into one of two treatment regimens. They were followed up for 3 months. RESULTS: VAS score at 2 weeks after the procedure was 4.19±1.32 in the control group, which was significantly (p<.05) higher than that (2.43±1.24) in the G group. VAS score at 6 weeks after the procedure was 4.00±1.23 in the control group and 3.22±1.45 in the G group, showing no significant (p=.077) difference between the two groups. There were no significant differences in functional outcomes at 6 or 12 weeks after the procedure. CONCLUSIONS: Compared with conventional cocktail used for SNRB, addition of HA-CMC sol showed effective control of rebound pain at 3 days to 2 weeks after the procedure.

The outcome of epiduroscopy treatment in patients with chronic low back pain and radicular pain, operated or non-operated for lumbar disc herniation: a retrospective study in 88 patients.

BACKGROUND: Patients with lumbar disc herniation are treated with physiotherapy/medication and some with surgery. However, even after technically successful surgery some develop a failed back syndrome with persistent pain. Our aim was to evaluate the efficacy of epiduroscopy in patients who suffer chronic low back pain and/or radicular pain with or without surgery and the gender difference in outcome. METHODS: A total of 88 patients were included with a mean age of 52 years (27-82), 54 women and 34 men. 66 of them were operated previously and 22 were non-operated. They all had persistent chronic back pain and radicular pain despite of medication and physical rehabilitation. Visual Analog Scale (VAS) for pain and Oswestry Disability Index (ODI) were evaluated preoperatively, after one month, six months and one-year after the epiduroscopy. RESULTS: All patients, and also the subgroups (gender and operated/non-operated) improved significantly in pain (VAS) and disability (ODI) at one month. A significant improvement was also seen at one year. No differences were found between men and woman at the different follow-up times. A slight worsening in VAS and ODI was noticed over time except for the non-operated group. CONCLUSIONS: Epiduroscopy helps to improve the back and leg pain due to lumbar disc herniation in the early stage. At one year an improvement still exists, and the non-operated group seems to benefit most of the procedure.

Which clinical and radiological variables could predict clinical outcomes of percutaneous endoscopic lumbar discectomy for treatment of patients with lumbosacral disc herniation?

BACKGROUND CONTEXT: Percutaneous endoscopic lumbar discectomy (PELD) is one of minimally invasive techniques to treat patients with low back and radiating pain resulting from lumbosacral disc herniation (LDH). PURPOSE: The purpose of this study is to evaluate the clinical efficacy of PELD to treat patients with low back and radicular pain due to LDH and to investigate which clinical and radiological variables have the ability to predict clinical outcome after PELD. STUDY DESIGN/SETTING: This is a retrospective study design carried out at a spine hospital. PATIENT SAMPLE: The sample comprised 75 patients who had undergone PELD for treatment of low back and radiating leg pain resulting from LDH and who could be followed up for at least 12 months. OUTCOMES MEASURES: Clinical outcomes were assessed using numeric rating scale for back and radiating leg pain (NRS back and leg), Oswestry Disability Index (ODI), and modified MacNab criteria at 1 month (short-term follow-up) and at least 12 months (long-term follow-up) after PELD. METHODS: The patients were divided into successful and unsuccessful outcome groups according to improvement of NRS back, NRS leg, and ODI (%) at long-term follow-up period. We compared the various clinical and radiological variables between the two groups to identify which variables could be the prognostic factors of clinical outcomes of PELD. This analysis was performed in terms of whole population, the subgroup of dominant back pain, and the subgroup of dominant leg pain, respectively. RESULTS: Significant improvements were observed in NRS back, NRS leg, ODI (%), and modified MacNab criteria at short-term and long-term follow-up after PELD. Positive straight leg raising (SLR) was significantly related to successful outcome as to NRS leg and ODI (%), and longer pain duration also showed significant relationship with unsuccessful outcomes as to NRS leg in whole population. Positive SLR had significant relationship with successful NRS leg as well as successful ODI (%) in the subgroup of dominant leg pain. CONCLUSIONS: PELD was an effective treatment in patients with back and leg pain due to LDH. Positive SLR had the predictive ability to successful reduction of radiating leg pain and successful functional improvement. Longer pain duration was also related to unsuccessful reduction of radiating leg pain.

The outcome of epiduroscopy treatment in patients with chronic low back pain and radicular pain, operated or non-operated for lumbar disc herniation: a retrospective study in 88 patients

BACKGROUND: Patients with lumbar disc herniation are treated with physiotherapy/medication and some with surgery. However, even after technically successful surgery some develop a failed back syndrome with persistent pain. Our aim was to evaluate the efficacy of epiduroscopy in patients who suffer chronic low back pain and/or radicular pain with or without surgery and the gender difference in outcome. METHODS: A total of 88 patients were included with a mean age of 52 years (27-82), 54 women and 34 men. 66 of them were operated previously and 22 were non-operated. They all had persistent chronic back pain and radicular pain despite of medication and physical rehabilitation. Visual Analog Scale (VAS) for pain and Oswestry Disability Index (ODI) were evaluated preoperatively, after one month, six months and one-year after the epiduroscopy. RESULTS: All patients, and also the subgroups (gender and operated/non-operated) improved significantly in pain (VAS) and disability (ODI) at one month. A significant improvement was also seen at one year. No differences were found between men and woman at the different follow-up times. A slight worsening in VAS and ODI was noticed over time except for the non-operated group. CONCLUSIONS: Epiduroscopy helps to improve the back and leg pain due to lumbar disc herniation in the early stage. At one year an improvement still exists, and the non-operated group seems to benefit most of the procedure.

Radiating Pain and Postural Balance with Pulsed Radiofrequency Treatment in Patients with Lumbosacral Radiculopathy

OBJECTIVE: To investigate the effect of pulsed radiofrequency (PRF) treatment on pain and balance in patients with lumbosacral radiculopathy.METHOD: This study included twenty-five patients who were diagnosed with chronic lumbosacral radiculopathy. They underwent PRF treatment in prone position under the fluoroscopic guidance. The effect of PRF was measured by the visual analog score (VAS). Patient ability to balance was evaluated by using the Tetra-ataxiometric posturography (Tetrax).RESULTS: After PRF all patients showed improvement in pain as measured by VAS (p < 0.001) and none of the patients reported any side effects. The posturographic balance, which was evaluated by Tetrax showed no significant decline after PRF treatment. The weight distribution index (WDI) with eyes open before treatment was 5.43 ± 2.88 and after treatment was 5.37 ± 2.65 (p=0.917). The mean stability index (SI) with eyes open before treatment was 16.52 ± 6.05 and after treatment was 16.61 ± 4.85 (p=0.906). The mean WDI with eyes closed before treatment was 5.66 ± 2.81 and after treatment was 5.16 ± 2.70 (p=0.470). Finally, the mean SI with eyes closed before was 25.88 ± 9.88 and after treatment was 25.99 ± 12.30 (p=0.962).CONCLUSION: The results suggest that PRF has an effect on pain in patients with chronic lumbosacral radiculopathy. The patients did not experience adverse effects, such as hypoesthesia, dysesthesia and decreased proprioception after PRF, and there were no significant declines in balance.

Group IV nociceptors develop axonal chemical sensitivity during neuritis and following treatment of the sciatic nerve with vinblastine.

We have previously shown that nerve inflammation (neuritis) and transient vinblastine application lead to axonal mechanical sensitivity in nociceptors innervating deep structures. We also have shown that these treatments reduce axonal transport and have proposed that this leads to functional accumulation of mechanically sensitive channels in the affected part of the axons. Though informing the etiology of mechanically induced pain, axonal mechanical sensitivity does not address the common report of ongoing radiating pain during neuritis, which could be secondary to the provocation of axonal chemical sensitivity. We proposed that neuritis and vinblastine application would induce sensitivities to noxious chemicals and that the number of chemo-sensitive channels would be increased at the affected site. In adult female rats, nerves were either untreated or treated with complete Freund's adjuvant (to induce neuritis) or vinblastine. After 3-7 days, dorsal root teased fiber recordings were taken from group IV neurons with axons within the sciatic nerve. Sciatic nerves were injected intraneurally with a combination of noxious inflammatory chemicals. Whereas no normal sciatic axons responded to this stimulus, 80% and 38% of axons responded in the neuritis and vinblastine groups, respectively. In separate experiments, sciatic nerves were partially ligated and treated with complete Freund's adjuvant or vinblastine (with controls), and after 3-5 days were immunolabeled for the histamine H3 receptor. The results support that both neuritis and vinblastine treatment reduce transport of the histamine H3 receptor. The finding that nociceptor axons can develop ectopic chemical sensitivity is consistent with ongoing radiating pain due to nerve inflammation.NEW & NOTEWORTHY Many patients suffer ongoing pain with no local pathology or apparent nerve injury. We show that nerve inflammation and transient application of vinblastine induce sensitivity of group IV nociceptor axons to a mixture of endogenous inflammatory chemicals. We also show that the same conditions reduce the axonal transport of the histamine H3 receptor. The results provide a mechanism for ongoing nociception from focal nerve inflammation or pressure without overt nerve damage.