Diagnosis and Treatment of Sciatica in the Netherlands: A Survey among Neurologists and Anesthesiologists.

BACKGROUND: This study aimed to assess how Dutch neurologists and anesthesiologists diagnose and treat people with sciatica in secondary care and to evaluate their adherence to the newest guidelines. METHODS: We conducted a cross-sectional survey. Respondents were asked about their current clinical practice related to sciatica. Three authors rated the respondents' adherence to the guidelines on a three-point Likert scale. RESULTS: Eighty neurologists and 44 anesthesiologists completed the questionnaire. Neurologists diagnose their sciatica patients primarily using a magnetic resonance imaging (89%). Selective diagnostic nerve blocks are considered useful by 81% of the neurologists. Neurologists primarily treat patients with pain medication, and 40% of them think epidural steroid injections are effective in 40-60% of injected patients. Twenty-nine percent of neurologists refer patients to a neurosurgeon after 4 months. Anesthesiologists consider a selective diagnostic nerve root block to have a higher diagnostic value than mapping. The most reported side effect of epidural injections is exacerbation of pain (82%). Pulse radiofrequency is applied in 9-11% of acute cases. The results also indicate that Dutch neurologists and anesthesiologists follow an evidence-based approach that is strictly or broadly in line with the guideline. CONCLUSIONS: Neurologists treat sciatica patients initially with pain medication and physiotherapy, followed by epidural steroid injections and referral for surgery. Anesthesiologists treat sciatica patients with one or more steroid injections or may perform a selective nerve root block. Imaging, selective nerve root blocks, medication, physiotherapy, and pulse radiofrequency are topics of further research.

A Prospective Study of Dorsal Root Ganglion Stimulation for Non-Operated Discogenic Low Back Pain.

INTRODUCTION: Disruptions of lumbar intervertebral discs may lead to severe discogenic low back pain (LBP). Severe pain has a deleterious effect on physical function and quality of life. Spinal cord stimulation (SCS) is a robust treatment for many neuropathic pain conditions. New innovations may be well-suited to treat neuropathic chronic LBP, including discogenic pain. The aim of this prospective study was to determine the effect of dorsal root ganglion (DRG) stimulation for a well-selected group of patients with discogenic LBP with no history of previous back surgeries. METHODS: Twenty subjects with confirmed discogenic LBP and no prior history of back surgery underwent trials of DRG stimulation and, if successful with at least 50% pain reduction, were permanently implanted. Subjects rated their pain, disability, quality of life, and mood at baseline, and 14 subjects were followed through 12 months of treatment. RESULTS: Treatment with DRG stimulation reduced LBP ratings (68.3% reduction), from mean 7.20 ± 1.3 at baseline to 2.29 ± 2.1 after 12 months (p = < 0.001). Oswestry ratings of disability significantly decreased (p = < 0.001) from 42.09 ± 12.9 at baseline to 21.54 ± 16.4 after six months of treatment and to 20.1 ± 16.6 after 12 months. The average quality of life EQ-5D index score at baseline was 0.61 ± 0.12 and 0.84 ± 0.13 after 12 months. DISCUSSION: DRG stimulation treatment for discogenic LBP improved the level of pain, function, and quality of life. Further research is necessary into efficacy of DRG stimulation in patients with chronic discogenic LBP and to determine the place of SCS in the treatment algorithm.

Clinical management of spinal metastases-The Dutch national guideline.

This article is a summary of the revised Dutch multidisciplinary evidence-based guideline 'Spinal metastases' (English translation available at: https://www.oncoline.nl/spinal-metastases) that was published at the end of 2015. This summary provides an easy-to-use overview for physicians to use in their daily practice.

The Dutch national guideline on metastases and hematological malignancies localized within the spine; a multidisciplinary collaboration towards timely and proactive management.

Here, we describe the development of a Dutch national guideline on metastases and hematological malignancies localized within the spine. The aim was to create a comprehensive guideline focusing on proactive management of these diseases, enabling healthcare professionals to weigh patient perspectives, life expectancy, and expected outcomes to make informed treatment recommendations. A national multidisciplinary panel consisting of clinicians, a nurse, a patient advocate, an epidemiologist, and a methodologist drafted the guideline. The important role of patients in the realization of the guideline enabled us to identify and address perceived shortcomings in patient care. The guideline covers not only metastatic epidural spinal cord compression, but also the treatment of uncomplicated metastases and hematological malignancies localized within the spine. The guideline is applicable in daily practice and provides an up-to-date and concise overview of the diagnostic and treatment possibilities for patients suffering from a disease that can have a serious impact on their quality of life. Suggestions for the practical implementation of patient care in hospitals are also provided, including approaches for pursuing proactive management. The crucial role of the patient in decision making is emphasized in this guideline.

No Transfer of Pressure to Adjacent Discs During Human Low-Pressure Controlled Discography: A Prospective Clinical Study.

Background: A substantial part of low back pain (LBP) originates from degeneration of the intervertebral disc. To confirm the diagnosis of discogenic pain, provocation discography seems the best available tool. However, provocation discography is also considered to be a controversial and subjective test because the patient's personal pain response is the most crucial for the result of the test. Recently, an in vivo porcine study and a study in nine human subjects showed passing of pressure to the adjacent discs during discography. This could mean that the concordant pain the patient describes originates from an adjacent disc. The object of this study is to assess if during human lumbar pressure-controlled provocation discography there is pressure transmission to adjacent discs. Methods: Consecutive patients between age 18 and 65 years with intractable low back pain and at least 50% preserved height of the suspected painful disc were included. Exclusion criteria were prior lumbar surgery of the suspected level, use of anticoagulants, pregnancy, local infection, and iodine allergy. An arterial blood pressure monitoring system simultaneously assessed the pressure in the adjacent discs while low-speed flow, pressure-controlled discography was performed. Results: In 50 patients with a positive discography, the average intradiscal peak pressure was 15.1 psi (SD = 11.1). In 48 procedures, no pressure rise in the adjacent discs was found. A small pressure rise (1.1 psi) in the adjacent disc during discography was recorded in two patients. Conclusions: Pressure rise in adjacent discs does not seem to occur during low-speed flow pressure-controlled lumbar provocation discography. False-positive pain reactions caused by potentially painful adjacent discs are therefore unlikely during pressure-controlled discography.

High-Frequency Spinal Cord Stimulation and Pregnancy: A Case Report.

INTRODUCTION: High-frequency spinal cord stimulation (HF SCS) is a relatively new modality of SCS. The present general advice concerning pregnancy and SCS, in general, is to turn the device off because of insufficient knowledge concerning the impact on the developing fetus. As HF stimulation generates higher energies, potential adverse fetal effects could be theoretically stronger. CASE: This case report describes a 36-year-old woman who had two pregnancies with an active HF SCS system. Her first pregnancy ended in a miscarriage. During her second pregnancy, she continued stimulation treatment during the whole pregnancy. She gave birth to a healthy baby. CONCLUSIONS: This case describes both a miscarriage and the birth of a healthy baby in a patient treated with HF SCS. It is not possible to rule out that the HF SCS could have caused the miscarriage. Also, the birth of the healthy baby after the second pregnancy in which HF SCS was used the whole period, is not a valid reason to declare HF SCS and SCS, in general, safe during pregnancy. As no sufficient data are available, we must remain cautious about any unknown possible adverse effects or delayed adverse events because of SCS and maybe especially HF stimulation. All outcome data on pregnancies during all types of SCS ideally should be collected and analyzed.

Paravertebral blockade for minor breast surgery.

UNLABELLED: Paravertebral blockade (PVB) has been advocated as a useful technique for breast surgery. We prospectively compared the efficacy of PVB via a catheter technique with the efficacy of general anesthesia (GA) for minor breast surgery. Thirty patients were randomized into two groups to receive either PVB or GA. Variables of efficacy were postoperative pain measured on a visual analog scale, postoperative nausea and vomiting (PONV), recovery time, and patient satisfaction. Postoperative visual analog scale scores in the PVB group were significantly lower in the early postoperative period (maximum, 12 vs 45 mm; P < 0.01). In both groups, PONV was nearly absent. There was no difference in recovery time. Patient satisfaction was better in the PVB group (2.8 vs 2.3; scale, 0-3; P < 0.01). There was one inadvertent epidural block and one inadvertent pleural puncture in the PVB group. Although PVB resulted in better postoperative pain relief, the advantages over GA were marginal in this patient group because postoperative pain was relatively mild and the incidence of PONV was small. Considering that the technique has a certain complication rate, we conclude that at present the risk/benefit ratio of PVB does not favor routine use for minor breast surgery. IMPLICATIONS: This study confirms the previously reported superior pain relief after paravertebral blockade (PVB) for breast surgery. However, considering the relatively mild postoperative pain and therefore the limited advantage of PVB for these patients, the risk/benefit ratio does not favor the routine use of PVB for minor breast surgery.