Practice variation in surgical treatment for lumbar degenerative disc disease: exploring regional and hospital factors influencing surgical rates.

The presence of significant, unwarranted variation in treatment suggests that clinical decision making also depends on where patients live instead of what they need and prefer. Historically, high practice variation in surgical treatment for lumbar degenerative disc disease (LDDD) has been documented. This study aimed to investigate current regional variation in surgical treatment for sciatica resulting from LDDD. We conducted a retrospective, cross-sectional analysis of all Dutch adults (>18 years) between 2016 and 2019. Demographic data from Statistics Netherlands were merged with a nationwide claims database, covering over 99% of the population. Inclusion criteria comprised LDDD diagnosis codes and relevant surgical codes. Practice variation was assessed at the level of postal code areas and hospital service areas (HSAs). Multivariable logistic regression analysis was employed to identify variables associated with surgical treatment. Among the 119,148 hospital visitors with LDDD, 14,840 underwent surgical treatment. Practice variation for laminectomies and discectomies showed less than two-fold variation in both postal code and HSAs. However, instrumented fusion surgery demonstrated a five-fold variation in postal code areas and three-fold variation in HSAs. Predictors of receiving surgical treatment included opioid prescription and patient referral status. Gender differences were observed, with males more likely to undergo laminectomy or discectomy, and females more likely to receive instrumented fusion surgery. Our study revealed low variation rates for discectomies and laminectomies, while indicating a high variation rate for instrumented fusion surgery in LDDD patients. High-quality research is needed on the extent of guideline implementation and its influence on practice variation.

Causal associations between gut microbiota with intervertebral disk degeneration, low back pain, and sciatica: a Mendelian randomization study.

PURPOSE: Although studies have suggested that gut microbiota may be associated with intervertebral disk disease, their causal relationship is unclear. This study aimed to investigate the causal relationship between the gut microbiota and its metabolic pathways with the risk of intervertebral disk degeneration (IVDD), low back pain (LBP), and sciatica. METHODS: Genetic variation data for 211 gut microbiota taxa at the phylum to genus level were obtained from the MiBioGen consortium. Genetic variation data for 105 taxa at the species level and 205 metabolic pathways were obtained from the Dutch Microbiome Project. Genetic variation data for disease outcomes were obtained from the FinnGen consortium. The causal relationships between the gut microbiota and its metabolic pathways and the risk of IVDD, LBP, and sciatica were evaluated via Mendelian randomization (MR). The robustness of the results was assessed through sensitivity analysis. RESULTS: Inverse variance weighting identified 46 taxa and 33 metabolic pathways that were causally related to IVDD, LBP, and sciatica. After correction by weighted median and MR-PRESSO, 15 taxa and nine pathways remained stable. After FDR correction, only the effect of the genus_Eubacterium coprostanoligenes group on IVDD remained stable. Sensitivity analyses showed no evidence of horizontal pleiotropy, heterogeneity, or reverse causation. CONCLUSION: Some microbial taxa and their metabolic pathways are causally related to IVDD, LBP, and sciatica and may serve as potential intervention targets. This study provides new insights into the mechanisms of gut microbiota-mediated development of intervertebral disk disease.

Associations of socioeconomic and lifestyle characteristics, psychological symptoms, multimorbidity, and multisite pain with sciatica - a 15-year longitudinal study.

BACKGROUND CONTEXT: Sciatica is defined as pain radiating from the low back to the leg, usually below the knee. It is a disabling condition that causes a major burden to health care and society. Previous evidence of the multifactorial etiology of sciatica comes mostly from cross-sectional studies. Larger, longitudinal studies with a multidimensional set of variables are needed. PURPOSE: To examine how socioeconomic and lifestyle characteristics, psychological symptoms, multimorbidity, and multisite pain are associated with sciatica. STUDY DESIGN: A longitudinal study of the Northern Finland Birth Cohort 1966. PATIENT SAMPLE: In total 6,683 working-aged members of the Northern Finland Birth Cohort 1966. OUTCOME MEASURES: Self-reported sciatic pain status over a 15-year study period. METHODS: We conducted a 15-year longitudinal study from the age of 31 to 46. We used multivariable generalized estimation equations analysis to examine how socioeconomic characteristics (low education, unemployment, and living alone), lifestyle characteristics (overweight, obesity, current smoking, and physical inactivity), psychological symptoms (depression, anxiety), multimorbidity, and multisite pain were associated with sciatica. RESULTS: At the age of 31, 21.1% of the study population reported sciatic pain and at the age of 46, 36.7%. Multisite pain was clearly the strongest factor associated with sciatica (odds ratio [OR] 2.61, 95% confidence interval [CI] 2.34‒2.92). In descending order of effect size, older age, low education, psychological symptoms, multimorbidity, overweight, obesity, physical inactivity and current smoking were positively associated with sciatica. Their ORs varied between 1.17 and 2.18. Living alone was negatively associated with sciatica (OR 0.81, 95% CI 0.72‒0.90). CONCLUSIONS: Multisite pain had the strongest association with sciatica. The effect sizes of the other factors were clearly smaller. To our knowledge this is the first study to evaluate the association of multisite pain with sciatica. This finding may have considerable implications for clinical work treating patients with sciatica.

Predictors of neuropathic pain and related functional disability in sciatica patients: a cross-sectional study.

PURPOSE: The aim of the present paper was to assess neuropathic pain and its predictors among patients with sciatica. In addition, we sought to investigate the predictors of functional disability in sciatica patients with neuropathic pain. METHODS: A cross-sectional study was carried out on a sample of 100 sciatica patients aged 18 years and older with a radiating pain from the lower back down to the leg below the knee. Information about socio-demographic characteristics, duration of symptoms, being treated or not, type of treatment, side of sciatica, presence of back pain, leg pain occurrence, leg pain intensity, functional disability and pain catastrophizing were collected. RESULTS: Of the total patients, 57% had neuropathic pain. Multivariable analysis showed that leg pain intensity was higher in the neuropathic pain group as compared to the non-neuropathic pain group. Also, patients with left sciatica were less likely to have neuropathic pain than patients with right sciatica. Patients with neuropathic pain having high levels of pain catastrophizing and being on bed rest for at least one week were at a higher risk of developing functional disability as compared to their counterparts. CONCLUSION: Low levels of pain catastrophizing and less bed rest should be considered in interventions aimed at improving the functional ability for sciatica patients with neuropathic pain.

Extending the straight leg raise test for improved clinical evaluation of sciatica: validity and diagnostic performance with reference to the magnetic resonance imaging.

BACKGROUND: The straight leg raise test (SLR) is one of the most utilized and studied physical tests in patients with low back pain (LBP) for the detection of lumbar disc herniation (LDH), showing high sensitivity and heterogeneous or low specificity. The high incidence of asymptomatic 'pathologic' findings in the magnetic resonance imaging (MRI) scans may cause verification bias to these results. We studied an extended SLR (ESLR) by adding location-specific structural differentiation movements (hip internal rotation or ankle dorsiflexion) to the traditional SLR for it to better differentiate neural symptoms from musculoskeletal. Previously, the ESLR has shown almost perfect interrater reliability between examiners and ability to detect sciatic patients. In this study, we investigated whether a 'positive' ESLR finding is associated with pathology seen on MRI. METHODS: Forty subjects comprised the study population, 20 in sciatic group and 20 in control group. The ESLR was performed 'blinded' to the subjects. After the ESLR, each subject's lumbar MRI was evaluated. The MRIs were analyzed independently by 2 senior radiologists and a spine specialist clinician. The ESLR and MRI results were cross-tabulated. To obtain the odds ratio (OR) with positive ESLR or SLR results for LDH or nerve root compression (NC), a binary logistic regression analysis with subjects' age, gender, height and weight was performed. ESLR's validity was assessed by combination of interrater agreement and percentage prevalence of both LDH and NC. RESULTS: Of sciatic (ESLR+) patients, 85 % had LDH and 75 % NC in the MRI. Not surprisingly, MRI showed a very high incidence of 'false-positive' findings with the ESLR negative group. The ESLR showed 0.85 sensitivity and 0.45 specificity for LDH and 0.75 sensitivity and 0.50 specificity for NC. A positive result in the ESLR was found to be strongly associated with for both LDH and NC: the OR was 8.0 (p = 0.028) and 5.6 (p = 0.041), respectively. CONCLUSIONS: The ESLR shows high validity in detecting neural symptoms and is strongly associated with pathology seen in the MRI when judged positive. We suggest the use of ESLR in clinical practice as a part of clinical examination, where it may prove to be a valuable tool in detecting patients with sciatic symptoms.

Sagittal Integral Morphotype of Female Classical Ballet Dancers and Predictors of Sciatica and Low Back Pain.

The aims of this study were to describe the sagittal integral morphotype (SIM) of classical ballet (CB) dancers, and to establish predictor factors and their cut off values for high risk of experiencing sciatica or low back pain (LBP). This retrospective cohort study was performed in 33 female professional CB dancers. Data related to anthropometric parameters, CB dance experience, sciatica or LBP history, and sagittal spine curvatures were collected. A binary logistic regression and receiver-operating characteristic analysis were performed. The main spine misalignments observed in the SIM of CB dancers were thoracic functional hyperkyphosis, hypomobile kyphosis, and hypokyphosis, and those for the lumbar curvature were hyperlordotic attitude and functional hyperkyphosis. The lumbar curvature in slump sitting and trunk forward bending positions, together with the stature, were significant predictor factors of sciatica history, while the years of dance experience was a significant predictor factor of LBP history. The cut off values analysis revealed that dancers with a stature of 161 cm or less, and those with 14 years of experience or more, have a greater probability of experiencing sciatica or LBP history, respectively.

Herpes zoster in patients with sciatica.

BACKGROUND: Several diseases are associated with herpes zoster (HZ). However, whether sciatica is a stressor leading to HZ development remains unclear. Here, we evaluated the occurrence of HZ in patients with sciatica. METHODS: The sciatica cohort consisted of patients first diagnosed as having sciatica between 2000 and 2012. All patients with sciatica were randomly age, sex and index year matched with control individuals without sciatica. The primary outcome was diagnosis of HZ. All individuals were followed until HZ diagnosis, withdrawal from the insurance, death, or December 31, 2013, whichever occurred first. HZ risk in the two cohorts was further analyzed with age, sex and comorbidity stratification. RESULTS: In total, 49,023 patients with sciatica and 49,023 matched controls were included. Female patients were more likely to have HZ development than were male patients [adjusted hazard ratio (HR) = 1.07, 95% confidence interval (CI) = 1.02-1.12]. After adjustments for all the covariates, HZ risk was significantly higher in the sciatica cohort than in the control cohort (adjusted HR = 1.19; 95% CI = 1.12-1.25). CONCLUSION: Sciatica increased HZ risk. Thus, HZ risk should be addressed whenever physicians encounter patients with sciatica, HZ vaccination should be considered especially those aged over 50.

Lumbar high-intensity zones on MRI: imaging biomarkers for severe, prolonged low back pain and sciatica in a population-based cohort.

BACKGROUND CONTEXT: There is often discrepancy between clinical presentation and lumbar magnetic resonance imaging (MRI) findings. PURPOSE: The purpose of this study was to assess the relationship of high-intensity zones (HIZs) on MRI with low back pain (LBP), sciatica, and back-related disability. STUDY DESIGN: Cross-sectional, population-based Southern Chinese cohort study. PATIENT SAMPLE: Of 1,414 possible participants, data from 1,214 participants (453 males, 761 females; mean age of 48.1±6.3 years) were included. OUTCOME MEASURES: Presence of single-level, homogeneous multilevel (same type HIZs of morphology and topography) and heterogeneous multilevel (mixed type HIZs of morphology and topography) HIZs and other MRI phenotypes were assessed at each level with T2-weighted 3T sagittal MRI of L1-S1. Associations with LBP, sciatica and Oswestry Disability Index were correlated with HIZ profiles. RESULTS: In all, 718 individuals had HIZs (59.1%). Disc degeneration/displacement were more prevalent in HIZ individuals (p<.001). HIZ subjects experienced prolonged severe LBP more frequently (39.6% vs. 32.5%; p<.05) and had higher Oswestry Disability Index scores (10.7±13.7 vs. 8.9±11.3; p<.05). Posterior multilevel HIZ were significantly associated with prolonged severe LBP (OR: 2.18; 95% CI:1.42-3.37; p<.05) in comparison to anterior only, anterior/posterior or other patterns of HIZ. Multilevel homogeneous or heterogeneous HIZs were significantly associated with prolonged, severe LBP (OR: 1.53-1.57; p<.05). Individuals with homogeneous HIZs had a higher risk of sciatica (OR: 1.51, 95% CI: 1.01-2.27; p<.05). CONCLUSIONS: This is the first large-scale study to note that lumbar HIZs, and specific patterns therein, are potentially clinically-relevant imaging biomarkers that are independently and significantly associated with prolonged/severe LBP and sciatica. HIZs, especially homogenous multilevel HIZ, should be noted in the global pain imaging phenotype assessment.

Low Back Pain (LBP), work and absenteeism.

BACKGROUND: Occupational physical demands are commonly assumed the cause of work-related Low Back Pain (LBP) and absenteeism. OBJECTIVES: To analyse relationships between LBP at work, physical demands and absenteeism. METHODS: Workers filled out a questionnaire on socio-demographic and work-related factors, general health, LBP (number of episodes in a 12-month period, pain severity and intensity), and occupational hazards related with physical demands. RESULTS: 735 workers completed the questionnaire (male n = 359). A high proportion of workers n = 507 (69%), from different occupational backgrounds, reported at least one LBP episode in the previous 12-month period. The highest ratio of subjects with more than 6 episodes of LBP per year was found among public services employees (31.8%) and the lowest ratio among administrative workers (10.3%). The highest ratio of workers (39%) were classified as sedentary workers, 34% of workers having a low or moderate level of physical demands in their work, and 27% reported high levels of physical demands in their work. There was a 4 % absenteeism rate in a 12-month period, which was significantly higher in the group with physically demanding work. Those subjects with higher physical requirements at work have increased odds of having more than 3 episodes of LBP during the previous year (p < 0.05) in comparison with subjects with more sedentary jobs and those with low or moderate physical demands. High intensity work, compared to sedentary work, is associated with an increased probability of being absent of work because of LBP in a previous 12-month period (OR = 3.12; CI 1.23-7.89; p = 0.016). CONCLUSIONS: Our findings suggest there is an association between highly physically demanding jobs, LBP and absenteeism. These results may contribute to the improvement of LBP assessment and prevention programs in Occupational Health Services.

Burden of Sciatica on US Medicare Recipients.

OBJECTIVE: This study evaluates the disease burden of sciatica on the US Medicare cohort. BACKGROUND DATA: Sciatica is a common disability that has important physical, mental, and economic effects. The Medicare Health Outcomes Survey (HOS) is a demographic and outcomes survey used to monitor the performance of Medicare Advantage health plans in the United States. The HOS includes data on demographics, chronic medical conditions, and patient-reported outcomes. METHODS: Medicare HOS data for cohorts from 2007 to 2013 were obtained. Patients were placed into two categories based on the survey results: with or without a history of sciatica. Baseline demographics, chronic medical conditions, and physical health symptoms were aggregated. In addition, average VR-12 physical component summary and mental component summary scores were calculated for each group at baseline and at 2-year follow-up. A Fisher exact test was used to assess significance for categorical variables, and a t-test was used for continuous variables. VR-12 changes as small as 1 to 2 units have been found to be clinically and socially relevant. RESULTS: The baseline cohort data of 1,000,952 patients yielded 250,869 patients (25%) who reported the diagnosis of sciatica, compared with 750,083 patients (75%) without sciatica. Patients with a history of sciatica tended to be younger, less educated, and notably with more medical comorbidities. Physical component summary outcomes were approximately 8 units lower in the sciatica group at baseline and 7 units lower at 2-year follow-up. Mental component summary outcomes were 6 units lower in the sciatica group at baseline and 5 units lower at 2-year follow-up. CONCLUSION: A large percentage of the US Medicare cohort suffers from symptomatic sciatica. Our study identified a 25% prevalence in the Medicare cohort. In addition, sciatica is associated with an increased incidence of comorbid medical conditions and poor health-related quality of life. LEVEL OF EVIDENCE: Level III STUDY DESIGN:: Observational-Cohort Study.

Risk Factors for Symptomatic Contralateral Foraminal Stenosis After Unilateral Transforaminal Lumbar Interbody Fusion.

OBJECTIVE: The most common cause of contralateral symptoms after unilateral transforaminal lumbar interbody fusion (TLIF) is contralateral foraminal stenosis (FS). This retrospective cohort study aimed to investigate the cause of and risk factors for contralateral FS after unilateral TLIF with a single cage. METHODS: Patients with degenerative lumbar spinal disorders who underwent unilateral TLIF at L4-5 were divided into 2 groups: those without contralateral radicular symptoms after surgery (group A; n = 340) and those with contralateral radicular symptoms after surgery (group B; n = 16). We investigated the influence of various radiological and cage-related factors on postoperative contralateral FS with radicular symptoms. The cage location indicates whether the cage's anterior tip crosses the disc midline-exceeding 50%-and in such a case, how far. RESULTS: Group B showed significantly increased postoperative coronal angle and sagittal angle and decreased contralateral foraminal height and foraminal area. Statistically significant (P < 0.01) factors according to the multivariate logistic regression analysis were the preoperative sagittal range of motion (odds ratio [OR]: 1.562, P = 0.004) and cage location (OR: 2.047, P = 0.015). The cutoff values for the sagittal range of motion and the cage location were 9.0° and 50.5%, respectively. The preoperative and postoperative 6-month visual analog scale scores and Oswestry disability index values were not significantly different between the groups. CONCLUSIONS: The 2 most meaningful risk factors were the preoperative sagittal range of motion and cage location. Inserting the cage beyond the disc midline, especially in patients with a high preoperative sagittal range of motion (≥9.0°), would help reduce postoperative complications.

New insight to the characteristics and clinical course of clusters of patients with imaging confirmed disc-related sciatica.

BACKGROUND: Referral to secondary care is common for a considerable proportion of patients with persistent sciatica symptoms. It is unclear if information from clinical assessment can further identify distinct subgroups of disc-related sciatica, with perhaps different clinical courses. AIMS: This study aims to identify and describe clusters of imaging confirmed disc-related sciatica patients using latent class analysis, and compare their clinical course. METHODS: The study population were 466 patients with disc-related sciatica. Variables from clinical assessment were included in the analysis. Characteristics of the identified clusters were described and their clinical course over 2 years was compared. RESULTS: A four-cluster solution was optimal. Cluster 1 (n = 110) had mild back and leg pain; cluster 2 (n = 59) had moderate back and leg pain; cluster 3 (n = 158) had mild back pain and severe leg pain; cluster 4 (n = 139) had severe back and leg pain. Patients in cluster 4 had the most severe profile in terms of disability, distress and comorbidity and the lowest reported global change and the smallest proportion of patients with a successful outcome at 2 years. Of the 135 patients who underwent surgery, 42% and 41% were in clusters 3 and 4, respectively. CONCLUSIONS: Using a strict diagnosis of sciatica, this work identified four clusters of patients primarily differentiated by back and leg pain severity. Patients with severe back and leg pain had the most severe profile at baseline and follow-up irrespective of intervention. This simple classification system may be useful when considering prognosis and management with sciatica patients. SIGNIFICANCE: Using data from a large observational prospective study, this work identifies four distinct clusters of patients with imaging confirmed disc-related sciatica. This classification could be used when considering prognosis and management with sciatica patients at their initial consultation.

Are 15-Year Trajectories of Low Back Pain and Sciatica Associated With Cardiovascular Autonomic Function in the General Population?: The Northern Finland Birth Cohort 1966 Study.

STUDY DESIGN: A population-based cohort study. OBJECTIVE: The aim of this study was to examine whether 15-year trajectories of low back pain (LBP) and sciatica are associated with cardiovascular autonomic function in a large general population sample. SUMMARY OF BACKGROUND DATA: Previous studies using mainly small patient samples have suggested that LBP and sciatica are associated with abnormal cardiovascular autonomic function, namely altered heart rate variability (HRV) and baroreflex sensitivity (BRS). We examined this association in a large general population sample. METHODS: The data collections of the Northern Finland Birth Cohort 1966 consisted of pain questionnaires at 31 and 46 years (history of LBP, sciatica, and other musculoskeletal pains during the previous year; yes/no for each) and measurements of HRV and BRS at 46 years (heart rate, HR; root mean square of successive differences in beat-to-beat intervals, rMSSD; low-frequency systolic blood pressure variability, SBPV; cross-spectral BRS, BRS; each while seated and standing). The data collections also comprised several confounders. Trajectories for LBP, sciatica, and both together ("no pain," "decreasing," "increasing," "long-term pain") were constructed and general linear models were used to perform comparisons between trajectories (for HR/rMSSD, n = 3398; for SBPV/BRS, n = 1667). RESULTS: In the crude models, LBP and sciatica were associated with higher HR, lower rMSSD, higher SBPV, and lower BRS, but these associations were mostly attenuated by adjustments. Regarding both LBP and sciatica, only the "increasing" trajectory was associated with two of the eight outcomes (standing SBPV, seated BRS) after adjustments. Regarding LBP, the "increasing" trajectory was associated with three (standing SBPV, seated BRS, standing BRS), the "long-term pain" trajectory with one (standing BRS), and the "decreasing" trajectory with one outcome (seated SBPV) after adjustments. Sciatica showed no association with the outcomes after adjustments. CONCLUSION: We conclude that the 15-year trajectories of LBP and sciatica do not have a consistent independent association with cardiovascular autonomic function among the general population. LEVEL OF EVIDENCE: 3.

Inflammatory biomarkers in patients with sciatica: a systematic review.

BACKGROUND: This systematic review focusses on inflammation as an underlying pathogenic mechanism in sciatica. We addressed two questions in particular: (1) what inflammatory biomarkers have been identified in patients with sciatica in the literature so far? 2) is there an association between the level of inflammatory activity and clinical symptoms? METHODS: The search was conducted up to December 19th 2018 in MEDLINE, EMBASE, CENTRAL and Web of Science. The study selection criteria: (1) observational cohort studies, cross-sectional studies and randomized clinical trials (RCT), (2) adult population (≥ 18 years) population with sciatica, (3) concentrations of inflammatory biomarkers measured in serum, cerebrospinal fluid (CSF) or biopsies, and (4) evaluation of clinically relevant outcome measures (pain or functional status). Three reviewers independently selected studies and extracted data regarding the study characteristics and the outcomes. Risk of Bias was evaluated using an adjusted version of the Quality in Prognosis Studies (QUIPS) tool. RESULTS: In total 16 articles fulfilled the criteria for inclusion: 7 cross sectional observational studies and 9 prospective cohort studies that included a total of 1212 patients. With regard to question 1) the following markers were identified: interleukin (IL)-1ß, IL-2, IL-4, IL-6, IL-8, IL-10, IL-17, IL-21, tumor necrosis factor-α (TNF-α), phospholipase A2, high sensitivity C-reactive protein (hsCRP), C-X-C motif chemokine 5 (CXCM5), CX3CL1, CCL2, epidermal growth factor (EGF), and monocyte chemotactic protein 4 (MCP-4). With regard to question 2) several positive correlations were found in longitudinal studies: a strong positive correlation between inflammatory mediators or byproducts and pain (measured by visual analogue scale, VAS) was found for IL-21 in two studies (r > 0,8), and moderate positive correlations for TNF-a in both serum (r = 0,629) and biopsy (r = 0.65); severe pain (VAS > 4) is associated with increased hsCRP levels among patients with sciatica (adjusted OR = 3.4 (95% CI, 1.1 to 10). CONCLUSION: In this systematic review there was considerable heterogeneity in the type of biomarkers and in the clinical measurements in the included studies. Taking into account the overall risk of bias of the included studies there is insufficient evidence to draw firm conclusions regarding the relationship between inflammation and clinical symptoms in patients with sciatica.

Work-related risk factors for sciatica leading to hospitalization.

The aim of this study was to assess the effects of the general strenuousness of work and various physical exposures on the risk of hospitalization for sciatica. The study population consisted of Finns aged 30 to 59 who had participated in a national health examination survey in 1978-80 (N = 3891). The participants were followed up until the end of 2011 and information on work-related determinants was acquired by a questionnaire. After adjustment for confounders, sedentary work involving handling fairly heavy objects/physically light work (HR 1.57; 95% CI 1.05-2.34), lifting or carrying heavy objects (2.10; 1.35-3.26) and exposure to whole-body vibration (1.61; 0.95-2.72) predicted sciatica, whereas heavier workloads appeared to reduce its risk (0.48; 0.26-0.89). There was an interaction between body mass index and exposure to whole-body vibration for the risk of sciatica. Overweight (1.94; 0.96-3.93) and obese (3.50; 1.44-8.46) participants exposed to whole-body vibration were at an increased risk of sciatica. Individuals of normal weight who were exposed to vibration, and overweight and obese individuals who were not exposed to vibration were not at an increased risk. The risk of hospitalization for sciatica seems to be highest among obese individuals exposed to whole-body vibration and among those lifting or carrying heavy objects.

Clinical findings from 104 cases of calving paralysis in dairy cows from Gippsland, Australia.

Case History: Dairy cows recumbent following calving on farms in South Gippsland, Australia were examined during two 3-month seasonal calving periods in 2011 and 2012 as part of a larger study of 218 recumbent cows. A cohort of 104 cows diagnosed with calving paralysis following dystocia was derived from the larger group, which were examined with 3 days of becoming recumbent. A thorough medical and musculoskeletal clinical examination was performed on each cow including flexor-withdrawal and patellar reflex tests, and postural assessment in the lifted position, unless the facilities were not available. Cows were diagnosed with one or more neurological syndromes: sciatic, tibial paresis, obturator or femoral, based on clinical findings consistent with damage to these peripheral nerves or their nerve roots. Clinical Findings: Evidence of sciatic syndrome was found in 100/104 (96.2%) cows and 146/172 (84.9%) affected hind limbs either as the sole neuropathy or in combination with tibial paresis, obturator or femoral syndromes. Pelvic damage was also present in 3/104 (2.8%) cows. Obturator syndrome was diagnosed in 30/104 (29%) cows and 45/172 (26.2%) affected hind limbs but not apparently as the sole reason for the recumbency. Femoral syndrome occurred in 16/104 (15.4%) cows and 21/172 (12.2%) affected hind limbs and was the only syndrome recorded in one cow. Clinical Relevance: Sciatic syndrome was the most common neurological syndrome observed in cows with calving paralysis. The other major nerves arising from the lumbo-sacral plexus were also affected and the various syndromes associated with damage to these nerves or their ventral nerve roots occurred in many combinations. Calving paralysis should be thought of as a paresis or paralysis resulting from damage to the ventral nerve roots of the lumbo-sacral plexus as any of the nerves originating from this plexus can be damaged during dystocia either individually or in combination with other nerves from the plexus.

Gadolinium Enhancement Is Not Associated With Disc Inflammation in Patients With Sciatica.

STUDY DESIGN: Retrospective observational histological study. OBJECTIVE: To evaluate the reliability of gadolinium enhancement as a marker for inflammation by associating gadolinium enhancement findings with the degree of inflammation as measured by macrophage infiltration in disc material retrieved during disc surgery in patients with sciatica. SUMMARY OF BACKGROUND DATA: Disc inflammation often occurs in sciatica patients, a noninvasive tool that is used to assess disc inflammation is Gadolinium enhanced MR imaging. METHODS: Disc tissue was retrieved from patients in the Sciatica trial (N = 119), a multicenter randomized controlled trial in patients with sciatica. Disc tissue was embedded in paraffin and stained with hematoxylin and CD68. Tissue samples were categorized as mild (0-10 macrophages/cm), moderate (10-100 macrophages/cm), and considerable (>100 macrophages/cm) inflammation. Of the 119 MRIs, 96 were additionally performed with contrast-enhanced gadolinium. RESULTS: Seventy-four patients showed gadolinium enhancement of the disc herniation and 26 of the nerve root. Degree of inflammation by macrophages was not associated with gadolinium enhancement of nerve roots or herniated discs. These results did not change if the patient groups with and without Modic type 2 changes were evaluated separately. Furthermore, no associations were observed between gadolinium enhancement and presence of Modic type 2 changes. CONCLUSION: This study found gadolinium enhanced MRI findings to be unreliable as an indicator for inflammation of disc herniation or nerve root in patients with sciatica. LEVEL OF EVIDENCE: 2.

Risk Factors for Low Back Pain: A Population-Based Longitudinal Study.

OBJECTIVE: To identify risk factors for low back pain (LBP) and lumbar radicular pain and to assess whether obesity and exposure to workload factors modify the effect of leisure-time physical activity on LBP and lumbar radicular pain. METHODS: The population of this 11-year longitudinal study consists of a nationally representative sample of Finns ages ≥30 years (n = 3,505). The outcomes of the study were LBP and lumbar radicular pain for >7 days or for >30 days in the past 12 months at follow-up. RESULTS: LBP and lumbar radicular pain were more common in women than in men. LBP slightly declined with increasing age, while lumbar radicular pain increased with age. Abdominal obesity (defined by waist circumference) increased the risk of LBP (adjusted odds ratio [OR] 1.40 [95% confidence interval (95% CI) 1.16-1.68] for LBP >7 days and adjusted OR 1.41 [95% CI 1.13-1.76] for LBP >30 days) and general obesity (defined by body mass index) increased the risk of lumbar radicular pain (adjusted OR 1.44 [95% CI 1.12-1.85] for pain >7 days and adjusted OR 1.62 [95% CI 1.16-2.26] for pain >30 days). Smoking and strenuous physical work increased the risk of both LBP and lumbar radicular pain. Walking or cycling to work reduced the risk of LBP, particularly LBP for >30 days (adjusted OR 0.75 [95% CI 0.59-0.95]), with the largest reductions among nonabdominally obese individuals and among those not exposed to physical workload factors. Using vibrating tools increased the risk of lumbar radicular pain. CONCLUSION: Lifestyle and physical workload factors increase the risk of LBP and lumbar radicular pain. Walking and cycling may have preventive potential for LBP.

Discrepancies Between Patient and Surgeon Expectations of Surgery for Sciatica: A Challenge for Informed Decision Making?

STUDY DESIGN: Qualitative study. OBJECTIVE: The objective of this study was to compare the perceptions of patients and surgeons regarding the risks and benefits of lumbar decompressive surgery for sciatica following a consultation meeting. SUMMARY OF BACKGROUND DATA: Evidence regarding pain improvement in patients following lumbar decompressive surgery for sciatica is inconsistent. Given this inconsistency, patients choosing to undergo lumbar decompressive surgery must accept the risks associated with the surgery despite uncertainty regarding benefits. This raises questions as to the nature of informed decision-making for patients choosing to undergo surgery for sciatica. METHODS: We undertook a qualitative descriptive study with 12 adult lumbar decompressive surgery candidates and six of their spine surgeons and analyzed data using inductive content analysis. RESULTS: Our analysis revealed that most patients were satisfied with the consultation despite limited understanding of lumbar decompressive surgery. We found discrepancies between patients' preoperative expectations and understanding of information provided by surgeons and what surgeons believed they had conveyed. Surgeons and patients disagreed on how much information is needed about postsurgical activity modifications and long-term outcomes to make a decision about whether or not to undergo surgery, with patients desiring more information. As a result, for most patients, the decision-making process extended beyond the information provided by surgeons and incorporated information from family members, friends, family doctors, and the internet. CONCLUSION: Our results highlight misunderstandings between patients and surgeons, particularly in regard to prognosis and activity modifications. Since this information is important for patients choosing whether to undergo a surgical intervention, our study provides guidance to improve informed decisions about sciatica and, potentially, other elective surgeries. LEVEL OF EVIDENCE: 4.

Retrolisthesis and lumbar disc herniation: a postoperative assessment of outcomes at 8-year follow-up.

BACKGROUND CONTEXT: Lumbar disc herniation and retrolisthesis have been shown to be significant degenerative changes that can be associated with back pain. Current literature has shown evidence that retrolisthesis is associated with similar baseline function in patients with L5-S1 disc herniation, but worse postoperative outcomes 2 years after lumbar discectomy. However, literature comparing long-term postoperative outcomes at 8-year follow-up in patients with L5-S1 disc herniation with retrolisthesis is lacking. PURPOSE: The purpose of the present study is to compare long-term postoperative outcomes at 8-year follow-up in patients with retrolisthesis and L5-S1 disc herniations to patients with L5-S1 disc herniations without retrolisthesis. STUDY DESIGN: Retrospective review of prospectively collected data from the Spine Patients Outcomes Research Trial (SPORT) database. PATIENT SAMPLE: Sixty-five patients who underwent lumbar discectomy for L5-S1 disc herniations with 8-year follow-up from the SPORT. OUTCOME MEASURES: Short Form (SF)-36 bodily pain scale, SF-36 physical function scale, Oswestry Disability Index, Sciatica Bothersomeness Index, and reoperation rate. METHODS: Baseline surgical parameters, length of stay, complication rates, reoperation rates, and outcome measures were recorded in the SPORT database. Follow-up data were collected at 6 weeks, 3 months, 6 months, 1 year, 2 years, 3 years, 4 years, 5 years, 6 years, 7 years, and 8 years. Retrolisthesis was defined as posterior subluxation ≥8%. Patients with and without retrolisthesis were compared using a mixed-effects model of longitudinal regression. Outcomes were calculated as time-weighted averages over 8 years. Reoperation rates were compared using the log-rank test based on time to first reoperation. RESULTS: One hundred-twenty five patients met inclusion criteria for the present study, including 29 patients with retrolisthesis (23.3%) and 96 patients who did not have retrolisthesis (76.7%). The greatest difference in clinical outcome measures was found at 2 years postoperatively. This was the only point at which both the Short Form-36 Bodily Pain scale (SF-36 BP) and PF showed significant differences between the retrolisthesis and nonretrolisthesis group. At 3 years, SF-36 BP was significantly lower in patients with retrolisthesis (39.9 vs. 52, p=.046). At 8-year follow-up, the presence of retrolisthesis in patients undergoing L5-S1 discectomy was not associated with worse outcome measure scores based on the area under the curve analysis for any metric investigated (SF-36 BP 41.4 vs. 47.1, p=.18; SF-36 Physical Function scale 38.9 vs. 45.4, p=.12; Oswestry Disability Index -39.4 vs. -34.8, p=.23; -11.6 vs. -10.4, p=.25) or a difference in reoperation rate (retrolisthesis group 10%, nonretrolisthesis group 17%, p=.41). CONCLUSIONS: While retrolisthesis can contribute to low back pain and dysfunction in patients undergoing lumbar discectomy for L5-S1 herniated nucleus pulposus in early follow-up, no significant difference was found in postoperative outcomes after 3 years. Additionally, retrolisthesis was not found to be associated with different reoperation rates at 8 years postoperatively.