Comparative Effectiveness of Lumbar Transforaminal Epidural Steroid Injections with Particulate Versus Nonparticulate Corticosteroids for Lumbar Radicular Pain due to Intervertebral Disc Herniation

Abstract

BACKGROUND:

Lumbar transforaminal epidural injections are commonly utilized to treat radicular pain due to intervertebral disc herniation.

OBJECTIVE:

This study aims to determine if there was a major difference in effectiveness between particulate and nonparticulate corticosteroids for acute radicular pain due to lumbardisc herniation.

DESIGN:

A multicenter, double blind, prospective, randomized trial on 78 consecutive subjects with acute uni-level disc herniation resulting in unilateral radicular pain. All subjects received a single level transforaminal epidural steroid injection with either dexamethasone or triamcinolone. Repeat injections were allowed as determined by the blinded physician and subjects. Primary outcomes included: number of injections received, surgical rates, and categorical pain scores at 2 weeks, 3 months, and 6 months. Secondary outcomes included mean Oswestry Disability Index.

RESULTS:

Both triamcinolone and dexamethasone resulted in statically significant improvements in pain and function at 2 weeks, 3 months, and 6 months, without clear differences between groups. The surgical rates were comparable with 14.6% of the dexamethasone group and 18.9% of the triamcinolone group receiving surgery. There was a statistically significant difference in the number of injections received, with 17.1% of the dexamethasone group receiving three injections vs only 2.7% of the triamcinolone group.

CONCLUSIONS:

Transforaminal epidural corticosteroid injections are an effective treatment for acute radicular pain due to disc herniation, and frequently only require 1 or 2 injections for symptomatic relief. Dexamethasone appears to possess reasonably similar effectiveness when compared with triamcinolone. However, the dexamethasone group received slightly more injections than the triamcinolone group to achieve the same outcomes.

Wiley Periodicals, Inc.

KEYWORDS:

Corticosteroid, Dexamethasone, Disc Herniation, Lumbar, Particulate, Radicular Pain, Radiculopathy, Transforaminal Epidural Injection, Triamcinolone

PMID:

 

24393129

 

[PubMed - as supplied by publisher]

Onset of complications following cervical manipulation due to malpractice in osteopathic treatment

Abstract

The aim of this study is to correlate cervical disc herniation with manipulation performed by a non-physician osteopath on a patient complaining of neck pain. The authors report a case in which a woman - treated with osteopathic spinal manipulation - developed cervical-brachial neuralgia following the cervical disc herniation. The patient then underwent surgery and was followed by physiotherapists. A clinical condition characterized by limitation of neck mobility, with pain and sensory deficit in the right arm and II-III fingers, still persists. The patient consulted the authors to establish whether cervical disc herniation could be attributed to manipulation. Adverse events or side effects of spinal manipulative therapy are relatively common and usually benign. Most of these side effects are mild or moderate, but sometimes they can be severe. Cervical manipulation can provoke complications less often than thoracic or lumbar manipulation. Furthermore, many diseases can be absolutely and relatively contraindicated to osteopathic treatment. Therefore, the knowledge of a patient's clinical conditions is essential before starting a manipulative treatment; otherwise the osteopath could be accused of malpractice. It is the authors' opinion that a cause-effect relationship exists between the manipulative treatment and the development of discherniation.

KEYWORDS:

complications to manipulation, disc herniation, malpractice, osteopathic manipulation treatment, osteopathy

PMID:

 

24402084

 

[PubMed - as supplied by publisher]

Differences in the Surgical Treatment of Recurrent Lumbar Disc Herniation Among Spine Surgeons in the United States

Abstract

BACKGROUND CONTEXT:

There are often multiple surgical treatment options for a spinal pathology. In addition, there is a lack of data that defines differences in surgical treatment among surgeons in the U.S.

PURPOSE:

To assess the surgical treatment patterns among neurological and orthopaedic spine surgeons in the United States for the treatment of one-and two-time recurrent lumbardisc herniation.

STUDY DESIGN:

Electronic Survey PATIENT SAMPLE: An electronic survey was delivered to 2560 Orthopaedic and Neurological surgeons in the U.S.

OUTCOME MEASURES:

The response data were analyzed to assess the differences among respondents over various demographic variables. The probability of disagreement is reported for various surgeon subgroups.

METHODS:

A survey of clinical and radiographic case scenarios that included a one- and two-time lumbar disc herniation was electronically delivered to 2560 Orthopaedic and Neurological surgeons in the U.S. The surgical treatment options were revision microdiscectomy, revision microdiscectomy with in-situ fusion, revision microdiscectomy with posterolateral fusion using pedicle screws, revision microdiscectomy with PLIF/TLIF, ALIF with percutaneous screws, ALIF with open posterior instrumentation, or none of the above. Significance of p=0.01 was used to account for multiple comparisons.

RESULTS:

445 surgeons (18%) completed the survey. Surgeons in practice 15+ years were more likely to select revision microdiscectomy compared with surgeons with fewer years in practice who were more likely to select revision microdiscectomy with PLIF/TLIF (p<0.001). Similarly, those surgeons performing 200+ surgeries per year were more likely to select revision microdiscectomy with PLIF/TLIF than those performing fewer surgeries (p=0.003). No significant differences were identified for region, specialty, fellowship training, or practice type. Overall, there was 69% and 22% probability that two randomly selected spine surgeons would disagree on the surgical treatment of two- and one-time recurrent discherniation, respectively. This probability of disagreement was consistent over multiple variables including geographic, practice type, fellowship training and annual case volume.

CONCLUSIONS:

Significant differences exist among U.S. spine surgeons in the surgical treatment of recurrent lumbar disc herniations. It will become increasingly important to understand the underlying reasons for these differences, and to define the most cost-effective surgical strategies for these common lumbar pathologies as the U.S. moves closer to a value-based health care system.

Copyright © 2014 Elsevier Inc. All rights reserved.

KEYWORDS:

disc herniation, electronic survey, practice trends, surgeon differences

PMID:

 

24462813

 

[PubMed - as supplied by publisher]

Type 1 Modic changes was a significant risk factor for 1 year outcome in sick-listed low back pain patients: a nested cohort study using magnetic resonance imaging of the lumbar spine

Abstract

BACKGROUND CONTEXT:

It is not clear whether Modic changes (MC) is associated with low back pain (LBP) outcome.

PURPOSE:

To study associations between baseline degenerative manifestations and outcome in sick-listed LBP patients.

STUDY DESIGN:

Prospective nested cohort study based on a randomised controlled trial.

PATIENT SAMPLE:

Out of 325 sick-listed LBP patients, 141 patients were consecutively examined by magnetic resonance imaging (MRI) and included, and 140 patients completed the study.

OUTCOME MEASURES:

Degenerative manifestations of the lumbar spine were quantified, and associations were studied in relation to the three primary outcomes 1) change of back+leg pain and 2) change of function as measured by Roland-Morris questionnaire and 3) one-year U-RTW.

METHODS:

By using a previously validated MRI-protocol, a specialist in radiology, who had no access to clinical data, described the images. Associations were studied by linear and logistic regression with adjustment for previously identified prognostic factors for one-year pain and function and for unsuccessful return to work (U-RTW).

RESULTS:

Clinically, 43% of the patients had radiculopathy. Degenerative changes were prevalent with altered disc contours in 84%, high intensity zones in 70% and nerve root touch or impingement in 63% of the patients. MC was identified in 60% of the patients, 18% with type 1 changes and 42% with type 2 changes, type 1 including both type 1 and type 1 in combination with type 2. Patients with type 1 changes reported more back pain and did not improve in pain or disability. They increased to include 30% of the patients with U-RTW at one year. Patients with type 2 changes did not differ significantly from patients without MC, but differed significantly from patients with type 1 changes in all three outcomes. Other degenerative manifestations were not significantly associated with any of the three outcomes.

CONCLUSIONS:

The only degenerative manifestation negatively associated with outcome was type 1 MC which affected 18% of the cohort at baseline and implied an increased risk for no improvement in pain and function and for U-RTW, even after adjustment for other prognostic factors.

Copyright © 2014 Elsevier Inc. All rights reserved.

KEYWORDS:

Low back pain, Modic changes, disc herniation, prognosis, return to work, sick-listing

PMID:

 

24534386

 

[PubMed - as supplied by publisher]

Reliability of Gadolinium-enhanced MRI findings and their correlation with clinical outcome in patients with sciatica

Abstract

BACKGROUND CONTEXT:

Gadolinium-enhanced Magnetic resonance imaging (Gd-MRI) is often performed in the evaluation of patients with persistent sciatica after lumbar discsurgery. However, correlation between enhancement findings and clinical findings is debated and limited data is available regarding the reliability of enhancement findings.

PURPOSE:

To evaluate the reliability of Gd-MRI findings and their correlation with clinical findings in patients with sciatica.

STUDY DESIGN/SETTING:

Prospective observational evaluation of patients who were enrolled in a randomized trial with one year follow-up.

PATIENTS SAMPLE:

Patients with 6-12 weeks sciatica who participated in a multicentre randomized clinical trial comparing an early surgery strategy to prolonged conservative care with surgery if needed. In total 204 patients underwent Gd-MRI at baseline and after one year.

OUTCOME MEASURES:

Patients were assessed by means of the Roland Disability Questionnaire (RDQ) for Sciatica, visual-analogue scale (VAS) for leg pain and patient-reported perceived recovery at one year. Kappa coefficients were used to assess interobserver reliability.

METHODS:

In total 204 patients underwent Gd-MRI at baseline and after one year. MRI findings were correlated to the outcome measures using The Mann-Whitney U test for continuous data and Fisher's exact tests for categorical data. This study was supported by a grant from the Netherlands Organisation for Health Research and Development (ZonMW) and the Hoelen Foundation, The Hague. None of the authors of this study has any conflict of interest.

RESULTS:

Poor to moderate agreement was observed regarding gadolinium enhancement of the herniated disc and compressed nerve root (kappa <0.41) which was in contrast with excellent interobserver agreement about the disc level of the herniated disc and compressed nerve root (kappa >0.95). Of the 59 patients with an enhancing herniated disc at one year, 86% reported recovery compared to 100% of the 12 patients with non-enhancing herniated discs (P=0.34). Of the 12 patients with enhancement of the most affected nerve root at one year 83% reported recovery compared to 85% of the 192 patients with no enhancement (P=0.69). Patients with and without enhancing herniated discs or nerve roots at one year reported comparable outcomes on RDQ and VAS-leg pain.

CONCLUSION:

Reliability of Gd-enhanced MRI findings was poor to moderate and no correlation was observed between enhancement findings and clinical findings at one year follow-up.

Copyright © 2014 Elsevier Inc. All rights reserved.

KEYWORDS:

Sciatica, clinical outcome, conservative treatment, disc herniation, follow-up, gadolinium-enhanced MRI findings, surgery

PMID:

 

24561397

 

[PubMed - as supplied by publisher]

Growth and Differentiation Factor-5 (GDF-5) in the Human Intervertebral Annulus Cells and Its Modulation by IL-1ß and TNF-α in Vitro

Growth and differentiation factor-5 (GDF-5) is a member of the TGF-ß superfamily which regulates cell division and differentiation. GDF-5 attracted high interest because of its role in skeletal development, especially in cartilaginous sites. Little is known, however, about the role of GFD-5 in disc cell biology. The present work demonstrated the immunohistologic presence of GDF-5 in human outer and inner annulus tissue. Microarray analysis of annulus cells showed significant upregulation of GDF-5 expression in herniated vs. non-herniatedlumbar discs (2.14fold change, p=0.021). In vitro three-dimensional culture studies challenged human annulus cells with IL-1ß and TNF-α, two proinflammatory cytokines known to be elevated in the human degenerating disc. Exposure resulted in significant downregulation of GDF-5 during both TNF-α exposure (5.83 fold change, p=0.044) and IL-1ß exposure (3.38 fold change, p=0.015). In vitro findings suggest that the degenerating discmilieu, with high proinflammatory cytokine levels, may limit expression of GDF-5, resulting in limited regenerative capacity of the intact disc.

Copyright © 2014. Published by Elsevier Inc.

KEYWORDS:

disc herniation, growth and differentiation factor-5, interleukin-1ß, intervertebral disc, proinflammatory cytokines, tumor necrosis factor-α

PMID:

 

24582800

 

[PubMed - as supplied by publisher]