The role of provocative discography in minimally invasive selective endoscopic discectomy.

A discogenic etiology is being widely accepted as a primary source of chronic low-back pain. Even though increasing information is available on the pathophysiology of the degenerated disc, the present MR techniques are still not capable of pin-pointing the source of this pain. In other words, with a non-invasive MR1 study we can still not define which disc is painful and what are the characteristics of discogenic pain from an imaging perspective. Discography remains therefore the only functional test that can delimit both morphologically and by provocation which discs are involved in the patents clinical picture. In combination with endoscopic procedures it helps tailor treatments. We consider that this diagnostic tool should be used routinely and performed by the surgeon himself as part of a screening-therapy protocol in spine surgery. We present our considerations regarding this diagnostic-screening method based on our clinical and surgical experience in patients who have been evaluated and have undergone selective endoscopic disscetomy after the screening.

Spinal nerve root repair and reimplantation of avulsed ventral roots into the spinal cord after brachial plexus injury.

OBJECT: The authors review the first series of 10 cases in which injured intraspinal brachial plexus were surgically repaired. They describe the technique of spinal cord implantation or repair of ruptured nerve roots, as well as patient outcome. METHODS: Spinal root repair/implantation was performed from 10 days to 9 months postinjury. There were nine male patients and one female patient. Postoperatively in most cases, regeneration of motor neurons from the spinal cord to denervated muscles could be demonstrated. The first signs of regeneration were noted approximately 9 to 12 months postoperatively. Useful function with muscle power of at least Medical Research Council Grade 3 occurred in three of 10 cases. Magnetic brain stimulation studies revealed a normal amplitude and latency from the cortex to reinnervated muscles on surgically treated and control sides. A certain degree of cocontraction between antagonistic muscles (for example, biceps-triceps) compromised function. With time there was a reduction of cocontractions, probably due to spinal cord plasticity. In these cases there was also, surprisingly, a return of sensory function, although the mechanism by which this occurred is uncertain. Sensory stimulation (thermal and mechanical) within the avulsed dermatomes was perceived abnormally and/or experienced at remote sites. There was some return of patients' sense of joint position. CONCLUSIONS: A short time lag between the accident and the surgery was recognized as a significant factor for a successful outcome. Reimplantation of avulsed nerve roots may be combined with other procedures such as nerve transfers in severe cases of brachial plexus injury.

Cost-minimisation analysis of three conservative treatment programmes in 180 patients sick-listed for acute low-back pain.

OBJECTIVE: To perform a cost-minimization analysis of three conservative treatment regimes for acute low-back pain (LBP). DESIGN: A prospective randomized clinical trial. Patients were assigned at random to one of three treatment programmes: General Practitioner Programme (GPP-) controls, Manual Therapy Programme (MTP) or Intensive Training Programme (ITP). SETTING: Primary care and physiotherapists in Stockholm, Sweden. PATIENTS: 180 patients sick-listed for acute LBP. MAIN OUTCOME MEASURES: Direct, indirect and total costs for three treatment programmes. RESULTS: The direct costs for treatment were lowest in the GPP group -- 2744 Swedish crowns (SEK) per patient. More patients in the MTP and ITP underwent operations for disk hernia and radiological investigations than in the GPP. Indirect costs, defined as sick-leave for LBP represent about 90% of the total cost. CONCLUSIONS: With respect to total costs, the findings were similar between the three treatment programmes. The GPP had the lowest direct costs. It is not possible to conclude which treatment programme is to be recommended as a least cost alternative. The strong effect of indirect costs on the total cost stresses that further studies should focus on methods of shortening sick-leave.

Prediction of functional disability, recurrences, and chronicity after 1 year in 180 patients who required sick leave for acute low-back pain.

The aim of the study was to identify factors that predict low-back pain outcome at 12 months and thus to identify patients at risk for poor long-term outcomes. One hundred-eighty patients, all disabled by acute low-back pain, were included. Outcome (dependent) variables were Oswestry disability score, recurrences during the study year, and chronicity defined as 90 or more days off work for low-back pain during the study year, or a disease-specific sick-leave rate (a variable created by the authors) of more than 25%. Stepwise logistic regression analysis was performed. Thirty-three percent of the patients had an Oswestry score greater than 25, indicating moderate disability at the 1-year follow-up evaluation. Pain on coughing at study entry predicted a high likelihood of disability at 1 year, with a threefold risk. Many work days missed as a result of low-back pain in the past 2 years and lack of stimulating work tasks predicted recurrences during the year. A high Oswestry score assessed at study entry was the only factor that predicted chronicity. The factors revealed in the current study should help the clinician to identify patients at risk. The authors propose that the revealed predictors should be investigated extensively at the patient's first visit for acute low-back pain.

Acute low-back-pain patients exhibit a fourfold increase in sick leave for other disorders: a case-control study.

One hundred eighty patients with acute low-back pain (LBP) were compared to 608 age- and sex-matched controls with regard to somatic and personality characteristics. The low-back-pain group had a fourfold increase (median) in sick-leave episodes for reasons other than spinal morbidity during the preceding 2 years. In the same period, the median number of episodes of sick leave for LBP was 1 in the patients and 0 in the controls. The mean number of days off for other reasons was 34 (median = 20.5) in the patients compared to 9 (median = 0) in the controls, and days off for LBP were 20 (median = 5) and 5 (median = 0), respectively. Analysis of other factors than those directly related to LBP disclosed significant differences in marital status and smoking habits between patients and controls. Furthermore, LBP patients estimated their work to be physically heavier. We conclude that medical intervention should focus not only on the spine, but also on a wide range of other aspects of the patient's situation. Even in the acute phase of LBP, the previous sick-leave records should be analyzed to provide adequate measures to prevent future sick leaves. Presently, the sociomedical costs for a subset of the population who repeatedly seek help for LBP are significantly higher than those for the non-LBP population.

Conservative treatment in patients sick-listed for acute low-back pain: a prospective randomised study with 12 months' follow-up.

We evaluated three different conservative treatment methods for acute low-back pain patients in groups following a manual therapy programme, an intensive training programme, or a general practitioner programme, the latter serving as the control group. Patients aged 19-64 years on sick leave for low-back pain with or without sciatica were included in a prospective randomised study evaluating outcomes such as impairment, pain, functional disability, socio-economic disability and satisfaction with the treatment or explanations. Evaluation by unbiased observers was performed at 1, 3 and 12 months. The three treatment groups were comparable at baseline. With regard to satisfaction, the patients in the manual therapy programme and those in the intensive training programme were more satisfied with the treatment than those in the general practitioner programme at all follow-ups. With regard to the explanations of current low-back pain episodes, the patients in the manual therapy programme were more satisfied than those in the general practitioner programme at all follow-ups. The manual therapy programme group were also more satisfied with the explanations than those in the intensive training programme at the 1-month follow-up. However, no differences were revealed between the groups with respect to outcomes on measures of impairment, pain, functional disability or socioeconomic disability. All three study groups showed rapid improvement. After 1 month a significant improvement was noted in all outcome values compared with the values on entry to the study. Within the limitations discussed in our study, it is concluded that (1) patients sick listed with acute low-back pain, with or without sciatica, will be significantly improved after 1 month regardless of conservative treatment programme; (2) they will be more satisfied with the treatment if they are referred to a manual treatment programme or a training treatment programme; (3) they will be more satisfied with the explanations of the acute low-back problem if they are referred to one of the above groups, especially the manual treatment group; (4) they will not show any other differences with respect to subjective and objective variables, either at short-term or at long-term follow-ups.