Effects of a concurrent exercise training program on low back and sciatic pain and pain disability in late pregnancy.

OBJECTIVE: The aim of the present study was to explore the influence of a concurrent exercise (aerobic + resistance) training program, from the 17th gestational week (g.w.) until birth on low back and sciatic pain, and pain disability. A total of 93 pregnant women divided into exercise (n = 49) and control (n = 44) groups followed a 60-min, 3 days/week, concurrent exercise training. METHODS: Low back and sciatic pain were measured with a Visual Analogic Scale (VAS). The disability resulting from pain was assessed with the Oswestry Disability Index (ODI). Measures were performed at the 16th and 34th g.w. RESULTS: The exercise group increased 21.9 mm less the VAS low back (between-group differences (B): 95% CI: -33.6 to -10.2; p < 0.001) and 12.9 mm less the VAS sciatica score (between-group differences: 95% CI (B): -21.8 to -4.0; p = 0.005) than the control group. Regarding the ODI questionnaire, the exercise group increased 0.7, 0.5, and 0.7 less than the control group in pain while sleeping (between-group differences (B): 95% CI: -1.4 to -0.01; p = 0.025), pain while lifting weight (between-group differences (B): 95% CI: -0.9 to -0.01; p = 0.016), and limitations of the social life due to pain (between-group differences(B): 95% CI: -1.3 to -0.06; p = 0.032). Furthermore, the exercise group suffered 6.9% less pain than the control group in the ODI total score (between-group differences (B): 95% CI: -13.9 to 0.053; p = 0.052). CONCLUSION: This concurrent exercise training program adapted to pregnant women improved pain compared to controls.

Increased local miR-21 expressions are linked with clinical severity in lumbar disc herniation patients with sciatic pain.

BACKGROUND: The miR-21 has been implicated in the process of neuroinflammation as well as neuropathic pain. OBJECTIVES: To explore the relationship between the plasma and local expression of miR-21 with disease severity of lumbar disc herniation (LDH) patients with sciatic pain. MATERIAL AND METHODS: Ninety-two LDH patients with sciatic pain and 25 scoliosis patients as painless controls were enrolled in the current study. Samples from nucleus pulposus (NP), annulus fibrosus (AF) and soft tissues around nerve root (STANR) were obtained. The plasma and local expressions of miR-21 were detected with quantitative reverse transcription polymerase chain reaction (qRT-PCR). The visual analogue scale (VAS) for lumbar pain and leg pain, and Japanese Orthopedic Association (JOA) score were selected to evaluate the clinical severity. The degree of disc compression on nerve was evaluated using the Pfirrmann grade based on the magnetic resonance imaging (MRI) findings. For the convenience of analysis, LDH patients with sciatic pain were classified into a severe pain (SP) group (VAS ≥ 6) and a mild-moderate pain (MP) group (VAS < 6). Receiver operating characteristic (ROC) curve analysis was performed to detect the potential diagnostic power of miR-21 with regard to the Pfirrmann grade. RESULTS: There were no significant differences in serum miR-21 expressions among SP LDH patients, MP LDH patients and scoliosis painless controls. Local expressions of miR-21 in STANR, AF and NP were all drastically upregulated in the SP group in comparison with the MP group and scoliosis painless group. Local NP and STANR miR-21 expressions were positively associated with the Pfirrmann grade. Local miR-21 expressions in STANR and AF were positively associated with VAS score and negatively related to JOA score. The ROC curve analysis indicated that both STANR and AF miR-21 expressions may serve as significant diagnostic factors for the Pfirrmann grade. CONCLUSIONS: Increased local miR-21 expressions are linked with clinical severity of LDH in patients with sciatic pain.

Inflammation in the intervertebral disc herniation. / Inflamación en la hernia del disco intervertebral.

Up until fairly recently, it was thought that sciatic pain in the lumbar herniated disc was caused by compression on the nerve root. However, the lumbar herniated disc shows mixed pictures which are difficult to explain by simple mechanical compromise. In recent years various immunology, immunohistochemistry and molecular biology studies have shown that the herniated tissue is not an inert material, but rather it Is biologically very active with the capability of expressing a series of inflammatory mediators: cytokines such as interleukin-1, interleukin-6, interleuquin-8 and tumor necrosis factor being the ones which stand out. The inflammation is not only induced by the chemical irritation of the bioactive substances released by the nucleus pulposus but also by an autoimmune response against itself. Thus, in addition to the mechanical factor, the biomechanical mediation plays an important role in the pathophysiology of sciatic pain and of radiculopathy. Through a review of a wide range of literature, we researched the cellular molecular mediators involved in this inflammatory process around the lumbar herniated disc and its involvement in sciatic pain.

Traditional Aspects of Sciatic Pain Management and Allied Therapies from Persian Medical Reports.

Sciatica is a common back pain caused by irritation of the sciatic nerve. Current pharmacologic therapies have proven inadequate for many patients with sciatic pain. On the other hand, there is a globally increasing demand for the use and administration of natural medicaments for this disorder. Traditional Persian Medicine (TPM) is a school of medicine and a medicinal plant-based resource for clinical studies put forward by Persian scholars. The aim of the present study is to gather and study the effectiveness of all medicinal plants from five main Persian pharmacopeias. Furthermore, different databases such as PubMed and Scopus have been checked to derive relevant activities for these plants. In all, 99 medicinal plants related to 42 families have been authenticated. Asteraceae and Apiaceae were the most frequent families and roots and seeds were the most reported botanical parts. The employed routes of administration were oral (54%), topical (33%) and rectal (13%). Anti-inflammatory, analgesic activity and antinociceptive properties of medicines are known as some main mechanisms to manage sciatic pain. These functions are possessed by 30%, 15%, and 15% of the studied plants, respectively. Medicaments that can be introduced as lead agents for further investigation are Zingiber officinale Roscoe, Olea europaea L., Strychnos nux-vomica L and Artemisia vulgaris L which showed all of these properties in previous studies. Hence, conducting adducible clinical trials using these lead agents may lead to novel drugs with lesser undesirable and much more therapeutic effects on controlling sciatic pain.

Effects of transcutaneous electrical nerve stimulation in the Management of Post-Injection Sciatic Pain in a non-randomized controlled clinical trial in Nnewi, Nigeria.

BACKGROUND: Many studies on transcutaneous electrical nerve stimulation (TENS) had been undertaken to explore its pain relieving efficiency on several medicals/surgical conditions but none, specifically, had been carried out to determine the effect it has on post-injection sciatic pain (PISP) which comes about from wrong administration of intramuscular pain. This study aims to assess the effects of TENS in the management of PISP. METHODS: A total of 72 PISP subjects comprising 40 test subjects and 32 control subjects participated in a non-randomized controlled clinical trial in the current study. Participants were recruited from Department of Physiotherapy, Nnamdi Azikiwe University Teaching Hospital, Nnewi and Landmark Physiotherapy Services, Nnewi. The participants were however blinded to the intervention method they will receive before being allotted conveniently to test/experimental group (TG) or control group (CG). A written informed consent was obtained from participants before enrollments in the study. TENS and sham TENS (STENS) was applied to 40 test and 32 subjects respectively, 3 times a week, and 1 hour per session for the 10 weeks the study lasted. The Visual Analogue Scale was used to collect baseline data as well as those of 2nd, 4th, 6th, 8th and 10th weeks after TENS and STENS interventions. The data analysis was performed with the Descriptive statistic of Mean ± SD, mean comparison test, repeated analysis of variance and paired wise t-test. Statistical level of significance was set at P < 0.05. RESULT: Results of repeated measure ANOVA showed that the pain level among participants in the treatment group at the end (after 10 weeks) of the intervention was significantly lower than that of their counterparts in the control group (F = 16.26; p = 0.01); with the intervention accounting for the 19% of the variance. The effect size (partial eta squared) = 0.19. CONCLUSION: The outcome of this research has proved the effectiveness of TENS in the management of PISP and is being recommended in the management of PISP. TRIAL REGISTRATION: Pan Africa Clinical Trial Registry ( PACTR201805003408271 ). The study was registered retrospectively on the 29th May, 2018.

Extraforaminal Discal Cyst as Cause of Radiculopathy.

We report the first extraforaminal location of a lumbar discal cyst. The patient was treated by hemilaminectomy, arthrectomy, cyst resection, and unilateral arthrodesis, achieving complete release of the nerve root. Extraforaminal lumbar discal cyst may represent an unexpected cause of sciatic pain with favorable outcome after surgical resection.

Short-Term Outcome Comparison Between Full-Endoscopic Interlaminar Approach and Open Minimally Invasive Microsurgical Technique for Treatment of Lumbar Disc Herniation.

OBJECTIVE: To compare postoperative pain control and functional outcome between full-endoscopic interlaminar approach (FEIA) and open minimally invasive microsurgical technique (MMST) for lumbar discectomy. METHODS: All consecutive patients treated with FEIA were prospectively followed. Clinical outcome parameters (low back and leg numeric rating scale and Quebec Back Pain Disability Scale) were measured. Analgesics use after surgery was quantified. Results were compared with a cohort of patients treated in the same period with MMST. The decision regarding which surgical technique to use was based on endoscope availability only. RESULTS: There were 26 patients treated with FEIA and 18 treated with MMST. Baseline patient characteristics were comparable. Sciatic pain was treated in both groups. Postoperative back pain was significantly lower in the FEIA group (numeric rating scale scores 1.5, 0.3, and 0.2 at 1, 2, and 4 weeks after FEIA vs. 3.6, 2.4, and 1.6 after MMST). In the FEIA group, 61.5% of patients did not take any pain medication. The average number of analgesics taken within 30 days was 4.0 in the FEIA group and 27.2 in the MMST group. The average Quebec Back Pain Disability Scale score decreased from 57.7 to 25.0, 18.0, and 14.2 at 1, 2, and 4 weeks after FEIA compared with a decrease from 58.8 to 41.1, 34.7, and 23.0 in the MMST group. No approach-related complications were reported. CONCLUSIONS: With less analgesic use, back and leg pain relief after 1 week in the FEIA group was comparable to that achieved in the MMST group after 1 month. This was also true for overall ability of patients to perform daily activities.

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)

Increased local expressions of CX3CL1 and CCL2 are related to clinical severity in lumbar disk herniation patients with sciatic pain.

BACKGROUND: Chemokines have been identified to be involved in the modulation of pain through both peripheral and central mechanisms. However, the role of chemokines in lumbar disk herniation (LDH) with sciatic pain remains unknown. OBJECTIVE: The current study was performed to explore the expression of two most commonly studied chemokines CX3CL1 and CCL2 and assess their associations with clinical severity in LDH patients with sciatic pain. METHODS: The soft tissues around nerve root (STANR), annulus fibrosus (AF), and nucleus pulposus (NP) biopsies were obtained from 36 LDH patients with chronic sciatic pain and 10 scoliosis patients (painless controls). The serum and local expressions of CX3CL1 and CCL2 were determined using enzyme-linked immunosorbent assay and Western blot analysis, respectively. The visual analog scale (VAS) scores for low back pain and lower extremity pain and Japanese Orthopaedic Association (JOA) scores were recorded on the day of hospital admission to evaluate the clinical severity. LDH patients with sciatic pain were divided into severe pain (SP) group (VAS ≥7; n=18) and mild-to-moderate pain (M-MP) group (VAS <7; n=18) for lower extremity pain. RESULTS: Local expressions instead of CX3CL1 and CCL2 in STANR, AF, and NP were significantly higher in the SP group than in M-MP compared with scoliosis painless group. Expressions of both CX3CL1 and CCL2 in STANR and AF were positively correlated with VAS scores for lower extremity and for low back pain, respectively. In addition, CX3CL1 and CCL2 expressions in STANR were negatively associated with JOA scores. There were no significant differences of serum CX3CL1 and CCL2 levels among SP group, M-MP group, and scoliosis painless group. CONCLUSION: Both CX3CL1 and CCL2 may play important roles in maintaining pain in LDH patients. Local blockade of CX3CL1 and CCL2 in LDH patients with persistent pain deserves further intensive study.

Auricular acupuncture diagnosis in patients with lumbar hernia.

BACKGROUND: Auricular Acupuncture Diagnosis is a diagnostic method which is essential for the topographic identification on the auricle of the anatomical parts of the body carrying a particular ailment or dysfunction. OBJECTIVE: To identify the specific zones related to lumbar hernia in patients treated with a series of epidural infiltrations with corticosteroids. METHODS: In a consecutive group of thirty patients with lumbar hernia 2 diagnostic methods used in Auricular Acupuncture Diagnosis, Pain Pressure Test and Electric Skin Resistance Test, were applied before the first infiltration (T0), before the second and the third infiltration (T1, T2) and one week after the third infiltration (T3). The parameters, whose variations were analyzed at T0-T3, were the following: the number of points identified; the intensity of pain on a verbal rating scale and the foot-hand distance in cm with bent spine and extended knees. The identified points were reported on the Auricular Sectogram which is a validated graphic system suitable for a correct transcription of the points and indicated for a statistical analysis of their distribution on the different sectors. RESULTS: A significant association was found for some auricular areas, along the series of epidural infiltrations, with a progressive reduction in the number of tender and low electrical resistance points together with a decrease of pain and hand-foot distance. CONCLUSIONS: The auricular zones found with Auricular Acupuncture Diagnosis in our group of patients seem of clinical relevance and could be included in the complementary treatment of lumbar-sciatic pain in lumbar hernia.

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

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

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

Aspects of conservative sciatic pain.

Successful multimodal conservative treatment of sciatic pain will prevent unfavorable results of life discectomy and accelerates the natural course. In assessment of modalities of conservative treatment of sciatic pain, somatic and psychosomatic aspects have to be considered. Severe neurological deficits caused by lumbar disc herniation have to be treated surgically. Conservative treatment of sciatic pain follows the etiopathogenetic hypothesis of a centrally triggered and radicularly terminated inflammation; it reflects the biopsychosocial paradigm. Inflammatory alterations in the disc and psychosocial peculiarities of the patients prove this disease model. Conservative treatment of sciatic pain does not determine its, but works by the combined operation of different but etiopathogenetic or scientifically efficient means. Somatic therapy aims at blocking the inflammatory cascade by peridural and systemic antiphlogistic drugs, sufficently applied analgethics and temporally limited bedrest. Physiotherapy and sports therapy for remobiliziation will follow. Psychosomatic therapy works through relaxation, support and interpretation. Physiotherapy, relaxation and verbal intervention work prophylacally, too. The patient-doctor relationship plays a crucial role in conservative treatment of sciatic pain.