Clinical assessment and management of lumbar spinal stenosis: clinical dilemmas and considerations for surgical referral.

Lumbar spinal stenosis is the leading indication for spine surgery in older adults. Surgery is recommended in clinical guidelines if non-surgical treatments have been provided with insufficient benefit. The difficulty for clinicians is that the current number of randomised controlled trials is low, which creates uncertainty about which treatments to provide. For non-surgical clinicians this paucity of data leads to a clinical dilemma of whether to continue managing the patient or refer to a spine surgeon. This Viewpoint aims to provide an update on the assessment of lumbar spinal stenosis, treatment recommendations, indications for referral to a spine surgeon, and current clinical dilemmas facing non-surgical clinicians and spinal surgeons.

Impact of a multidisciplinary team meeting on patient-reported outcomes at 2 years after lumbar surgery: A prospective comparative exploratory study.

Failed back surgery syndrome is a challenge. We hypothesized that a multidisciplinary team meeting (MTM) may be useful to select patients who are the most likely to benefit from lumbar surgery. We conducted an observational, prospective, comparative, exploratory study. We aimed to compare core clinical patient-reported outcomes at 2 years after lumbar surgery between patients who attended a MTM and those who did not. Patients who underwent lumbar surgery for a degenerative disease, in a single academic orthopedic department, between January and September 2018, were consecutively screened. Eligible patients were surveyed between April and June 2020. Patient-reported outcomes included lumbar and radicular pain, spine-specific activity limitations and health-related quality of life assessed via self-administered questionnaires. Outcomes were compared between respondents who attended the MTM and those who did not. Overall, 211 patients underwent lumbar surgery, 108 were eligible and 44 included: 11 attended the MTM and 33 did not. Mean participants' age was 57.4 (15.4) years, symptom duration was 14.8 (15.3) months, lumbar pain was 51.3 (18.2) and radicular pain was 53.4 (18.6). At 2 years, we found no evidence that lumbar and radicular pain, activity limitations and health-related quality of life differed between the 2 groups. The decrease was -26.8 (41.1) versus -20.8 (30.4) in lumbar pain and -25.5 (43.0) versus -19.5 (27.5) in radicular pain, in participants who attended the MTM versus those who did not, respectively. We found no evidence that core clinical patient-reported outcomes at 2 years after lumbar surgery differed between participants who attended the MTM and those who did not. However, the exploratory design of our study does not allow concluding that MTMs do not have an impact.

Determinants of apprehension to return to sport after reconstruction of the anterior cruciate ligament: an exploratory observational retrospective study.

BACKGROUND: Only 65% of people return to a level of sport equivalent to that before after anterior cruciate ligament (ACL) surgery. Persisting apprehension may in part explain this observation. We aimed to describe characteristics of people with ACL-Return to Sport after Injury (RSI) scores ≥ 60/100 (low apprehension) at 6 months after injury and to identify variables independently associated with low apprehension at 6 months. METHODS: We conducted a single-center retrospective study. People who had surgery for an ACL rupture and who participated in an outpatient post-operative rehabilitation program were included consecutively. The ACL-RSI questionnaire was self-administered at 6 months after injury. Baseline characteristics of people with ACL-RSI scores ≥ 60/100 and < 60/100 were described. Multiple logistic regression was performed to identify baseline variables associated with low apprehension at 6 months. RESULTS: We included 37 participants: 13/37 (35.1%) were women and mean age was 27.2 (9.2) years. At 6 months, 21/37 (56.8%) had an ACL-RSI score ≥ 60/100. Participants who had an ACL-RSI score ≥ 60/100 more often received a preoperative rehabilitation (16/21 [76.2%] vs 5/16 [31.2%]), and had less often knee pain (7/21 [33.3%] vs 7/16 [43.7%]) and effusion (5/21 [23.8%] vs 8/16 [50.0%]) at 1 month after surgery, than participants who had an ACL-RSI score < 60/100. In the multivariate analysis, preoperative rehabilitation was associated with low apprehension at 6 months (OR [95% CI] = 0.107 [0.023 to 0.488], p = 0.002). CONCLUSIONS: Preoperative rehabilitation was independently associated with low apprehension at 6 months. TRIAL REGISTRATION: Not applicable.

Effect of Prehabilitation Before Total Knee Replacement for Knee Osteoarthritis on Functional Outcomes: A Randomized Clinical Trial.

Importance: Multidisciplinary prehabilitation before total knee replacement (TKR) for osteoarthritis may improve outcomes in the postoperative period. Objective: To compare multidisciplinary prehabilitation with usual care before TKR for osteoarthritis in terms of functional independence and activity limitations after surgery. Design, Setting, and Participants: This prospective, open-label randomized clinical trial recruited participants 50 to 85 years of age with knee osteoarthritis according to the American College of Rheumatology criteria for whom a TKR was scheduled at 3 French tertiary care centers. Recruitment started on October 4, 2012, with follow-up completed on November 29, 2017. Statistical analyses were conducted from March 29, 2018, to March 6, 2019. Interventions: Four supervised sessions of multidisciplinary rehabilitation and education (2 sessions per week, at least 2 months before TKR, delivered to groups of 4-6 participants at each investigating center; session duration was 90 minutes and included 30 minutes of education followed by 60 minutes of exercise therapy) or usual care (information booklet and standard advice by the orthopedic surgeon) before TKR. Main Outcomes and Measures: The short-term primary end point was the proportion of participants achieving functional independence a mean (SD) of 4 (1) days after surgery defined as level 3 on the 4 functional tests. The midterm primary end point was activity limitations within 6 months after TKR assessed by the area under the receiver operating characteristic curve of the self-administered Western Ontario Questionnaire and McMaster Universities Osteoarthritis Index function subscale. Results: A total of 262 patients (mean [SD] age, 68.6 [8.0] years; 178 women [68%]) were randomized (131 to each group). A mean (SD) of 4 (1) days after surgery, 34 of 101 (34%) in the experimental group vs 26 of 95 (27%) in the control group achieved functional independence (risk ratio, 1.4; 97.5% CI, 0.9-2.1; P = .15). At 6 months, the mean (SD) area under the curve for the Western Ontario Questionnaire and McMaster Universities Osteoarthritis Index function subscale was 38.1 (16.5) mm2 in the experimental group vs 40.6 (17.8) mm2 in the control group (absolute difference, -2.8 mm2; 97.5% CI, -7.8 to 2.3; P = .31 after multiple imputation). No differences were found in secondary outcomes. Conclusions and Relevance: This randomized clinical trial found no evidence that multidisciplinary prehabilitation before TKR for osteoarthritis improves short-term functional independence or reduces midterm activity limitations after surgery. Trial registration: ClinicalTrials.gov Identifier: NCT01671917.

Posttraumatic Osteoarthritis Damage in Mice: From Histological and Micro-Computed Tomodensitometric Changes to Gait Disturbance.

OBJECTIVES: Osteoarthritis is a painful joint disease responsible for walking impairment. Its quantitative assessment by gait analysis in mice may be a relevant and noninvasive strategy to assess the disease severity. In this study, we aimed to determine the severity of osteoarthritis at the tissular and gait levels in unilateral and bilateral posttraumatic murine osteoarthritis. METHODS: Twenty-four C57BL/6 male mice were randomly assigned to 3 groups (n = 8/group): controls, unilateral surgery, and bilateral surgery. Posttraumatic osteoarthritis was induced unilaterally or bilaterally by destabilization of the medial meniscus. Gait analysis was performed weekly with the CatWalkTM XT system until the 16th week after surgery. After animal sacrifices, histological and micro-computed tomographic assessment was performed. RESULTS: Operated knees showed a significant increase in the histological score compared with controls (P < 0.001). Calcified anterior medial meniscal bone volume was higher on the ipsilateral side after unilateral destabilization of the medial meniscus (P < 0.001) and on both sides after bilateral intervention (P < 0.01). One week after surgery, the mice mean speed decreased significantly in both operated groups (P < 0.001 and P < 0.05). In the unilateral group, a significant increase in the contralateral hind print area appeared from week 4 to week 16. CONCLUSIONS: While bilateral destabilization of the medial meniscus induced no detectable gait modification except 1 week after surgery, unilateral model was responsible for a gait disturbance on the contralateral side. Further studies are needed to better define the place of the CatWalkTM in the evaluation of mouse models of osteoarthritis.

Conservative treatment for chronic coccydynia: a 36-month prospective observational study of 115 patients.

PURPOSE: To describe long-term outcomes of conservative treatment for chronic coccydynia. METHODS: We conducted a 36-month prospective observational study. Adults with chronic coccydynia (> 2 months) were included. The first-line treatment was coccygeal corticosteroid injection. The second-line treatment was either manual therapy or coccygectomy. The primary endpoint was the mean variation from baseline of coccydynia intensity at 6 and 36 months, using a numeric rating scale (0, no pain; 10, maximal pain). Evolution was considered unfavorable when coccydynia intensity was > 3 of 10 points at 36 months or coccygectomy had been performed. We carried out bivariate and multivariate analyses to identify variables associated with an unfavorable evolution. RESULTS: We included 115 participants. Mean (SD) age was 43.5 (12.3) years, duration of coccydynia 18.4 (21.6) months and coccydynia intensity 6.5 (2.0) of 10 points. Mean variations for coccydynia intensity were - 1.5 (3.0) at 6 months and - 2.8 (3.2) at 36 months. At 36 months, 59/115 (51%) participants had an unfavorable evolution. In bivariate analysis, posterior coccyx dislocations were numerically more frequent in participants with an unfavorable evolution compared to others (29/59 (48%) versus 17/56 (30%), p = 0.057). In multivariate analysis, longer duration of coccydynia was associated with an unfavorable evolution (OR = 1.04, 95% CI from 1.01 to 1.07, p = 0.023). CONCLUSION: In adults with chronic coccydynia receiving conservative treatment, symptoms decrease overtime, but significantly persist at 36 months in more than half of them. For patients with posterior coccyx dislocation, coccygectomy may be considered rapidly.

Rehabilitation and lumbar surgery: the French recommendations for clinical practice.

BACKGROUND: Indications and techniques of rehabilitation differ widely across types of lumbar surgery, including timing (before or after surgery) and prescriptions (surgeons but also medical or paramedical professionals). OBJECTIVES: This project aimed to build consensual recommendations for practice in this context. METHODS: The SOFMER methodology was used to establish recommendations for physical medicine and rehabilitation: a steering committee defined the types of lumbar surgery involved and developed the main questions to be addressed; a scientific committee performed a literature review for grading evidence and proposed the first version of recommendations, which were discussed during a dedicated session at the national Physical and Rehabilitation Medicine congress; then an e-Delphi method with cross-professional experts was used to finalise recommendations and reach a multidisciplinary consensus. RESULTS: The main questions developed were the value of rehabilitation before and after surgery, timing and type of rehabilitation, benefit of supervision and instrumental rehabilitation, value of patient education, and complementary interventions concerning rehabilitation for discectomy, fusion, and disc prosthesis (excluding decompression for spinal stenosis). The literature review identified 60 articles, but for several of the questions, no article in the literature addressed the issue. The multidisciplinary scientific committee analysed the literature and addressed the questions to propose the first version of a set of 23 recommendations. The congress session failed to answer all questions or to reach consensus for all items. After a three-step e-Delphi, 20 recommendations were retained, for which consensus among experts was reached. The recommendations are applicable only to patients without a neurological lesion. CONCLUSIONS: These recommendations provide important and consensual knowledge to assist clinicians in decision-making for rehabilitation in lumbar surgery. Despite many of the recommendations relying exclusively on expert opinion rather than published evidence, this approach is an important advance to improve concordance among healthcare professionals.

Development of a new patient-reported outcome measure assessing activities and participation in people with lumbar spinal stenosis: The Cochin Spinal Stenosis 19-item questionnaire.

BACKGROUND: Lumbar spinal stenosis (LSS) is the leading cause of spinal surgery in people over 65-years old. In people with LSS, generic self-administered questionnaires are the most commonly used PROs to assess health-related quality of life, global activity limitation, and low back pain-located activity limitation. AIM: The aim was to develop a new patient-reported outcome measure assessing activities and participation in people with LSS. DESIGN: Observation, prospective and qualitative study. SETTING: For the qualitative study, were enrolled in- and outpatients with LSS from 2 French tertiary care centers (Department of PRM of Cochin Hospital and Department of Rheumatology of Limoges Hospital). For the Internet E-survey, screened the electronic medical records of the Department of PRM of Cochin Hospital. POPULATION: From February to April 2018 were enrolled patients older than 50-years and symptomatic LSS. METHODS: We used a 2-step approach. In a first step, we conducted a qualitative study using in-depth semi-structured interviews in 20 patients with LSS to collect meaningful concepts and to develop a provisional questionnaire. In a second step, using the provisional questionnaire, we conducted an Internet E-survey in an independent sample of 200 patients with LSS. RESULTS: Concepts collected from patients generated a 48-item provisional questionnaire. Overall, 63/200 (31.5%) patients completed the provisional questionnaire. Item reduction resulted in a 19-item questionnaire, the Cochin Spinal Stenosis 19-item (CSS-19) questionnaire. Principal component analysis extracted 3 factors. In confirmatory analysis, factor 1 influenced all items. We found convergent validity with low back pain, LSS-specific disability and divergent validity with mental health-related quality of life. Cronbach α coefficient (95% CI) was 0.96 (0.94; 0.97). ICC was 0.90 (0.70; 0.97). Bland and Altman analysis found no systematic trend for test-retest. CONCLUSIONS: CSS-19 is a new patient-reported outcome measure assessing activities and participation in people with LSS. Its construction prioritized patients' perspectives at all stages. Its content and construct validities are good. CLINICAL REHABILITATION IMPACT: Instruments able to capture specific needs of people with LSS in terms of activities and participation are lacking.

Diagnosis and management of lumbar spinal stenosis in primary care in France: a survey of general practitioners.

BACKGROUND: Lumbar spinal stenosis (LSS) is a common spinal condition and the most frequent indication for spinal surgery in elderly people. General practitioners (GPs) are on the 1st line for its diagnosis and treatment. We aimed to assess how GPs diagnose and treat people with LSS in France. METHODS: We conducted a cross-sectional survey in a primary care setting. French GPs were selected by a random draw from the French Medical Board. The questionnaire was designed by 3 physicians specialized in physical and rehabilitation medicine and a resident in general practice. A provisional questionnaire was tested in a pilot survey of 11 French GPs. Participants' feedbacks served to build the final questionnaire. This latter was submitted by e-mail or mail to 330 GPs. GPs were surveyed about the 3 main domains relevant to the management of people with LSS in primary care: 1/ diagnosis, 2/ pharmacological treatments and 3/ non-pharmacological treatments, using self-administered open- and closed-ended questions and visual analog scales. RESULTS: Overall, 90/330 (27.3%) GPs completed the survey. 51/89 (57.3%) GPs were confident with managing people with LSS. Low back pain 51/87 (58.6%), neurogenic claudication 38/87 (43.7%) and paresthesia in the lower limbs 31/87 (35.6%) were the 3 most frequently cited clinical signs leading to the diagnosis of LSS. Improvement with lumbar flexion was mentioned by 9/87 (10.3%) GPs. 85/86 (98.8%) would consider prescribing lumbar imaging, 60/84 (71.4%) corticoid spinal injections and 42/79 (53.2%) would never prescribe lumbar flexion-based endurance training. All GPs would refer people with LSS to another specialist. CONCLUSIONS: French GPs lack confidence with diagnosing LSS and prescribing pharmacological and non-pharmacological treatments for people with LSS.

Mechanical Stretch of High Magnitude Provokes Axonal Injury, Elongation of Paranodal Junctions, and Signaling Alterations in Oligodendrocytes.

Increasing findings suggest that demyelination may play an important role in the pathophysiology of brain injury, but the exact mechanisms underlying such damage are not well known. Mechanical tensile strain of brain tissue occurs during traumatic brain injury. Several studies have investigated the cellular and molecular events following a static tensile strain of physiological magnitude on individual cells such as oligodendrocytes. However, the pathobiological impact of high-magnitude mechanical strain on oligodendrocytes and myelinated fibers remains under investigated. In this study, we reported that an applied mechanical tensile strain of 30% on mouse organotypic culture of cerebellar slices induced axonal injury and elongation of paranodal junctions, two hallmarks of brain trauma. It was also able to activate MAPK-ERK1/2 signaling, a stretch-induced responsive pathway. The same tensile strain applied to mouse oligodendrocytes in primary culture induced a profound damage to cell morphology, partial cell loss, and a decrease of myelin protein expression. The lower tensile strain of 20% also caused cell loss and the remaining oligodendrocytes appeared retracted with decreased myelin protein expression. Finally, high-magnitude tensile strain applied to 158N oligodendroglial cells altered myelin protein expression, dampened MAPK-ERK1/2 and MAPK-p38 signaling, and enhanced the production of reactive oxygen species. The latter was accompanied by increased protein oxidation and an alteration of anti-oxidant defense that was strain magnitude-dependent. In conclusion, mechanical stretch of high magnitude provokes axonal injury with significant alterations in oligodendrocyte biology that could initiate demyelination.

Reduction of the Serum Levels of a Specific Biomarker of Cartilage Degradation (Coll2-1) by Hyaluronic Acid (KARTILAGE® CROSS) Compared to Placebo in Painful Knee Osteoarthritis Patients: the EPIKART Study, a Pilot Prospective Comparative Randomized Double Blind Trial.

BACKGROUND: Viscosupplementation is a symptomatic treatment of the knee osteoarthritis based on the intra-articular injection of hyaluronic acid (IAHA). Although many studies have investigated its effect on symptoms, few clinical studies have focused on its effects on biologicals markers of cartilage metabolism. In this study, we assessed the effect of an intra-articular injection of a reticulated hyaluronic acid compound on the level of a specific biomarker of type II collagen degradation. METHODS: Eighty one patients with symptomatic knee osteoarthritis were included in this randomized placebo controlled trial testing a reticulated hyaluronic acid (HA) with mannitol (KARTILAGE® CROSS, 16 mg/ml, one single injection of 2.2 mL; IAHA) versus saline solution. Primary outcome was the percentage of patients with a reduction of at least 10 nmol/l of serum Coll2-1 between baseline and day 90 (D90, 3 months after injection). Secondary outcomes concerned clinical evaluation and tolerance to the study product. RESULTS: A significant effect of IAHA was revealed by the sensitivity analysis of the decrease in cartilage marker. In the intention-to-treat population, the percentage of patients showing a decrease in the levels of serum Coll2-1 between inclusion and D90 showed was higher in HA (56.8%) than in placebo group (28.6%; P = 0.01). The same significant difference was observed between groups in the per protocol population (57.1% vs 29.0%; P = 0.02) corresponding to all patients having received the intra-articular injection (IA), being evaluated for the primary outcome on D-10 and D90, and with no major defined deviation. No significant differences between groups were observed on the changes in function (Lequesne index) or pain and on the number of adverse events. CONCLUSIONS: This is the first randomized double-blind placebo controlled trial showing that IA injection of reticulated HA with mannitol in knee osteoarthritis patients can reduce the serum levels of Coll2-1, a marker specific of type II collagen degradation. This finding suggests that IAHA may have a beneficial effect on cartilage degradation and that Coll2-1 could be used for the assessment of a single intra-articular treatment in clinical trials. TRIAL REGISTRATION: NCT02951585 ; clinicaltrial.gov. Retrospectively registered on October 28, 2016.

Resveratrol, Potential Therapeutic Interest in Joint Disorders: A Critical Narrative Review.

Trans-resveratrol (t-Res) is a natural compound of a family of hydroxystilbenes found in a variety of spermatophyte plants. Because of its effects on lipids and arachidonic acid metabolisms, and its antioxidant activity, t-Res is considered as the major cardioprotective component of red wine, leading to the "French Paradox" health concept. In the past decade, research on the effects of resveratrol on human health has developed considerably in diverse fields such as cancer, neurodegenerative and cardiovascular diseases, and metabolic disorders. In the field of rheumatic disorders, in vitro evidence suggest anti-inflammatory, anti-catabolic, anti-apoptotic and anti-oxidative properties of t-Res in various articular cell types, including chondrocytes and synoviocytes, along with immunomodulation properties on T and B lymphocytes. In preclinical models of osteoarthritis and rheumatoid arthritis, resveratrol has shown joint protective effects, mainly mediated by decreased production of pro-inflammatory and pro-degradative soluble factors, and modulation of cellular and humoral responses. Herein, we comprehensively reviewed evidence supporting a potential therapeutic interest of t-Res in treating symptoms related to rheumatic disorders.

Efficacy and safety of hyaluronic acid in the management of osteoarthritis: Evidence from real-life setting trials and surveys.

The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) treatment algorithm recommends intra-articular (IA) hyaluronic acid (HA) for management of knee osteoarthritis (OA) as second-line treatment in patients who remain symptomatic despite use of non-steroidal anti-inflammatory drugs (NSAIDs). This recommendation is based upon accumulating evidence that IA HA provides a significant benefit in knee OA. There is good evidence that IA HA injections reduce pain and increase function in knee OA, and the benefits are long-lasting as compared with IA corticosteroids. Evidence from real-life studies of repeat courses of IA HA demonstrates an improvement in pain or function lasting up to 40 months (12 months after the last injection cycle), a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement (TKR) of around 2 years. The clinical benefit of IA HA on knee OA may be 2-fold: (i) mechanical viscosupplementation of the joint (allowing lubrication and shock absorption) and (ii) the re-establishment of joint homeostasis through induction of endogenous HA production, which continues long after the exogenous injection has left the joint. The magnitude of the clinical effect may be different for different HA products, but this has not been proven so far and requires further investigation. IA HA injections are generally considered to be safe, although a slightly higher number of cases of local reactions and post-injection non-septic arthritis has been reported with high molecular weight cross-linked HAs. The use of IA HA in knee OA patients with mild-moderate disease, and for more severe patients wishing to delay TKR surgery, is recommended by the ESCEO task force. Further investigation into the OA patient types most likely to benefit from IA HA is warranted. Viscosupplementation with IA HA is a safe and effective component of the multi-modal management of knee OA.

A consensus statement on the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) algorithm for the management of knee osteoarthritis-From evidence-based medicine to the real-life setting.

The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) published a treatment algorithm for the management of knee osteoarthritis (OA) in 2014, which provides practical guidance for the prioritization of interventions. Further analysis of real-world data for OA provides additional evidence in support of pharmacological interventions, in terms of management of OA pain and function, avoidance of adverse events, disease-modifying effects and long-term outcomes, e.g., delay of total joint replacement surgery, and pharmacoeconomic factors such as reduction in healthcare resource utilization. This article provides an updated assessment of the literature for selected interventions in OA, focusing on real-life data, with the aim of providing easy-to-follow advice on how to establish a treatment flow in patients with knee OA in primary care clinical practice, in support of the clinicians' individualized assessment of the patient. In step 1, background maintenance therapy with symptomatic slow-acting drugs for osteoarthritis (SYSADOAs) is recommended, for which high-quality evidence is provided only for the prescription formulations of patented crystalline glucosamine sulfate and chondroitin sulfate. Paracetamol may be added for rescue analgesia only, due to limited efficacy and increasing safety signals. Topical non-steroidal anti-inflammatory drugs (NSAIDs) may provide additional symptomatic treatment with the same degree of efficacy as oral NSAIDs without the systemic safety concerns. Oral NSAIDs maintain a central role in step 2 advanced management of persistent symptoms. However, oral NSAIDs are highly heterogeneous in terms of gastrointestinal and cardiovascular safety profile, and patient stratification with careful treatment selection is advocated to maximize the risk:benefit ratio. Intra-articular hyaluronic acid as a next step provides sustained clinical benefit with effects lasting up to 6 months after a short-course of weekly injections. As a last step before surgery, the slow titration of sustained-release tramadol, a weak opioid, affords sustained analgesia with improved tolerability.

Tumor necrosis factor-α blockade in recurrent and disabling chronic sciatica associated with post-operative peridural lumbar fibrosis: results of a double-blind, placebo randomized controlled study.

INTRODUCTION: The aim of this study was to assess the efficacy and safety of tumor necrosis factor (TNF)-α inhibition with infliximab (IFX) in treating recurrent and disabling chronic sciatica pain associated with post-operative peridural lumbar fibrosis. METHOD: A double-blind, placebo-controlled study randomized 35 patients presenting with sciatica pain associated with post-operative peridural lumbar fibrosis to two groups: IFX (n = 18), a single intravenous injection of 3 mg/kg IFX; and placebo (n = 17), a single saline serum injection. The primary outcome was a 50 % reduction in sciatica pain on a visual analog scale (VAS) at day 10. Secondary outcomes were radicular and lumbar VAS pain at day 0 and radicular and lumbar VAS pain, Québec disability score, drug-sparing effect and tolerance at days 10, 30, 90, and 180. RESULTS: At day 10, the placebo and IFX groups did not differ in the primary outcome (50 % reduction in sciatica pain observed in three (17.6 %) versus five (27.8 %) patients; p = 0.69). The number of patients reaching the patient acceptable symptom state for radicular pain was significantly higher in the placebo than IFX group after injection (12 (70.6 %) versus five (27.8 %) patients; p = 0.01). The two groups were comparable for all other secondary outcomes. CONCLUSION: Treatment with a single 3 mg/kg IFX injection for post-operative peridural lumbar fibrosis-associated sciatica pain does not significantly reduce radicular symptoms at day 10 after injection. TRIAL REGISTRATION: ClinicalTrials.gov NCT00385086 ; registered 4 October 2006 (last updated 15 October 2015).

[Physical therapy, orthosis and occupational therapy in medical and surgical rheumatologic hand diseases]. / Rééducation de la main en pathologies médicale et chirurgicale : ergothérapie, orthèse et kinésithérapie.

Hand pathology can cause functional disability and deterioration in the quality of life by altering the grip and therefore, it requires a complex approach by a multidisciplinary team, including physiotherapists and occupational therapists. Orthoses are an important part of the treatment of these pathologies. A thorough understanding of the pathogenesis of lesions and their risk of progression to deformities is required for an appropriate use. Their fabrication by a specialized therapist and also their monitoring assure a good compliance. Their effectiveness depends on the patient adherence, for which information and education are essential. The role of physiotherapist is to establish a personalised rehabilitation program, including passive and active exercises and also the prevention of joint stiffness. The main goal after surgery is to initiate an early active motion in order to decrease the risk of adhesions without compromising the suture by the use of a splint. The role of occupational therapist is important all along the treatment period, from the early rehabilitation to the moment of return to home environment. The literature search shows that there is a lack of good methodological clinical studies in order to assess the effectiveness and the costs of this medical treatment.

Hypoxia induces nitric oxide synthase in rheumatoid synoviocytes: consequences on NADPH oxidase regulation.

We investigated the effects of hypoxia on inducible NO synthase (iNOS) activity and expression in rheumatoid arthritis (RA) synoviocytes. We further studied the relationship between nitrosative stress and NADPH oxidase (NOX) in such conditions. Human cultured synoviocytes were treated for 24 hours with IL-1ß, TNF-α or neither, and submitted to hypoxia or normoxia for the last 6 hours. Nitrite production and iNOS expression were increased under hypoxia conditions in RA cells in comparison to normoxia. Hypoxia did not potentate the basal and cytokine-induced superoxide productions, while NOXs' subunit expression and p47-phox phosphorylation were increased. Nitrosylation of NOXs and p47-phox was not raised under hypoxia conditions. Finally, peroxynitrite production was significantly increased under hypoxia conditions, in comparison to normoxia. Our results provide evidence for upregulation of iNOS and NOX activities in RA synoviocytes under hypoxia conditions, associated to an increased peroxynitrite production. Synovial cell metabolism under hypoxia conditions might be different from that in normoxia.

Comparative study of MRI and power Doppler ultrasonography of the heel in patients with spondyloarthritis with and without heel pain and in controls.

INTRODUCTION: Imaging of heel enthesopathy in spondyloarthritis (SpA) could potentially be useful for diagnosis and monitoring. The aim of this study was to assess the diagnostic capacities of MRI and power Doppler ultrasonography (PDUS) of the heel to distinguish patients with SpA from controls and to distinguish between patients with SpA with and without enthesopathy. METHODS: A cross-sectional single-centre study was performed in 51 patients (102 heels) with definite SpA according to Amor's criteria. Patients with degenerative non-inflammatory low back pain (n=24, 48 heels) were included as controls. Bilateral heel MRI and PDUS were performed by two senior musculoskeletal radiologists blinded to the clinical and biological data on the same day as the clinical evaluation. The data were analysed by patient and by heel. RESULTS: Neither MRI nor PDUS could discriminate between patients with SpA and controls; bone oedema on MRI was the only abnormality specific to SpA (94%), but with a poor sensitivity (22%). However, among patients with SpA, painful heels had more inflammatory abnormalities (81% by MRI, 58% by PDUS) than heels with no pain (56% at MRI, 17% at PDUS). CONCLUSION: Heel MRI and PDUS frequently show inflammatory lesions in SpA, particularly in painful heels. However, they were also often abnormal in controls. These results suggest that heel MRI and PDUS cannot be used for the diagnosis of SpA. However, PDUS and MRI may be useful for the depiction and assessment of enthesis inflammatory lesions in patients with SpA with heel pain.

[Pathophysiology of osteoarthritis: updated concepts]. / Physiopathologie de l'arthrose: conceptions actuelles.

Osteoarthritis is a whole joint disease including: cartilage, synovial tissue, subchondral bone, ligaments, muscles, and tendons. Cartilage is the main target tissue of the disease. Mechanical stress is a key regulator in osteoarthritis development and progression. Inflammation is a key regulator in osteoarthritis development and progression. The weight of genetic factors, mechanical stress, inflammation, and hormonal status is variable from a joint to another.