Evaluation of persons with suspected lumbosacral and cervical radiculopathy: Electrodiagnostic assessment and implications for treatment and outcomes (Part I).

Persons with back, neck, and limb symptoms constitute a major referral population to specialists in electrodiagnostic (EDX) medicine. The evaluation of these patients involves consideration of both the common and less common disorders. The EDX examination with needle electromyography (EMG) is the most important means of testing for radiculopathy. This test has modest sensitivity but high specificity and well complements imaging of the spine. Needle EMG in combination with nerve conduction testing is valuable in excluding entrapment neuropathies and polyneuropathy-conditions that frequently mimic radicular symptoms. In this first of a two-part review, the optimal EDX evaluation of persons with suspected radiculopathy is presented. In part two, the implications of EDX findings for diagnosis and clinical management of persons with radiculopathy are reviewed.

The Belgian national guideline on low back pain and radicular pain: key roles for rehabilitation, assessment of rehabilitation potential and the PRM specialist.

Low back pain (LBP) and radicular pain are very common health problems. They are rarely caused by serious underlying pathology and will usually recover spontaneously in time. In about one third of the cases however, the pain and functional impairment will persist one year after onset, being responsible for high health care costs and work absence. The management of LBP and radicular pain should focus therefore on excluding signs and symptoms of serious underlying pathology, on an active approach and on the prevention of chronicity. In 2017 the Belgian Health Care Knowledge Centre (KCE) published a guideline on LBP and radicular pain. This guideline formed the basis for a national pathway on LBP and radicular pain and is the first step to change and optimize our daily clinical practice. In this Belgian guideline the importance is stressed of a comprehensive clinical assessment and a tailored rehabilitation. Pharmacological and invasive treatments have a more doubtful effect or should only be considered under certain conditions. Implementing these recommendations in an interdisciplinary pathway necessitates a central role for Physical and Rehabilitation Medicine (PRM) especially in giving advice on and/or coordinating the tailored rehabilitation to prevent chronicity. To do this, the PRM specialist should perform a medical and functional assessment according to the ICF framework and taking into account the risk for chronicity or persistent impairment and the rehabilitation potential.

Nerve root block versus surgery (NERVES) for the treatment of radicular pain secondary to a prolapsed intervertebral disc herniation: study protocol for a multi-centre randomised controlled trial.

BACKGROUND: Sciatica is a common condition reported to affect over 3% of the UK population at any time and is often caused by a prolapsed intervertebral disc (PID). Although the duration and severity of symptoms can vary, pain persisting beyond 6 weeks is unlikely to recover spontaneously and may require investigation and treatment. Currently, there is no specific care pathway for sciatica in the National Health Service (NHS), and no direct comparison exists between surgical microdiscectomy and transforaminal epidural steroid injection (TFESI). The NERVES (NErve Root block VErsus Surgery) trial aims to address this by comparing clinical and cost-effectiveness of surgical microdiscectomy and TFESI to treat sciatica secondary to a PID. METHODS/DESIGN: A total of 163 patients were recruited from NHS out-patient clinics across the UK and randomised to either microdiscectomy or TFESI. Adult patients (aged 16-65 years) with sciatic pain endured for between 6 weeks and 12 months are eligible if their symptoms have not been improved by at least one form of conservative (non-operative) treatment and they are willing to provide consent. Patients will be excluded if they present with neurological deficit or have had previous surgery at the same level. The primary outcome is patient-reported disability measured using the Oswestry Disability Questionnaire (ODQ) score at 18 weeks post randomisation and secondary outcomes include disability and pain scales using numerical pain ratings, modified Roland-Morris and Core Outcome Measures Index at 12-weekly intervals, and patient satisfaction at 54 weeks. Cost-effectiveness and quality of life (QOL) will be assessed using the EQ-5D-5 L and self-report cost data at 12-weekly intervals and Hospital Episode Statistics (HES) data. Adverse event data will be collected. Analysis will follow the principle of intention-to-treat. DISCUSSION: NERVES is the first trial to evaluate the comparative clinical and cost-effectiveness of microdiscectomy to local anaesthetic and steroid administered via TFESI. The results of this research may facilitate the development of an evidence-based treatment strategy for patients with sciatica. TRIAL REGISTRATION: ISRCTN, ID: ISRCTN04820368 . Registered on 5 June 2014. EudraCT EudraCT2014-002751-25. Registered on 8 October 2014.

Lessons learnt from a discontinued randomised controlled trial: adalimumab injection compared with placebo for patients receiving physiotherapy treatment for sciatica (Subcutaneous Injection of Adalimumab Trial compared with Control: SCIATiC).

BACKGROUND: Adalimumab, a biological treatment targeting tumour necrosis factor α, might be useful in sciatica. This paper describes the challenges faced when developing a new treatment pathway for a randomised controlled trial of adalimumab for people with sciatica, as well as the reasons why the trial discussed was stopped early. METHODS: A pragmatic, parallel group, randomised controlled trial with blinded (masked) participants, clinicians, outcome assessment and statistical analysis was conducted in six UK sites. Participants were identified and recruited from general practices, musculoskeletal services and outpatient physiotherapy clinics. They were adults with persistent symptoms of sciatica of 1 to 6 months' duration with moderate to high level of disability. Eligibility was assessed by research physiotherapists according to clinical criteria, and participants were randomised to receive two doses of adalimumab (80 mg then 40 mg 2 weeks later) or saline placebo subcutaneous injections in the posterior lateral thigh. Both groups were referred for a course of physiotherapy. Outcomes were measured at baseline, 6-week, 6-month and 12-month follow-up. The main outcome measure was disability measured using the Oswestry Disability Index. The planned sample size was 332, with the first 50 in an internal pilot phase. RESULTS: The internal pilot phase was discontinued after 10 months from opening owing to low recruitment (two of the six sites active, eight participants recruited). There were several challenges: contractual delays; one site did not complete contract negotiations, and two sites signed contracts shortly before trial closure; site withdrawal owing to patient safety concerns; difficulties obtaining excess treatment costs; and in the two sites that did recruit, recruitment was slower than planned because of operational issues and low uptake by potential participants. CONCLUSIONS: Improved patient care requires robust clinical research within contexts in which treatments can realistically be provided. Step changes in treatment, such as the introduction of biologic treatments for severe sciatica, raise complex issues that can delay trial initiation and retard recruitment. Additional preparatory work might be required before testing novel treatments. A randomised controlled trial of tumour necrosis factor-α blockade is still needed to determine its cost-effectiveness in severe sciatica. TRIAL REGISTRATION: Current Controlled Trials, ISRCTN14569274 . Registered on 15 December 2014.

PRECISE--pregabalin in addition to usual care: statistical analysis plan.

BACKGROUND: Sciatica is a severe, disabling condition that lacks high quality evidence for effective treatment strategies. This a priori statistical analysis plan describes the methodology of analysis for the PRECISE study. METHODS/DESIGN: PRECISE is a prospectively registered, double blind, randomised placebo controlled trial of pregabalin compared to placebo, in addition to usual care in patients with sciatica. The aim of this study is to determine the efficacy and cost-effectiveness of pregabalin in reducing leg pain intensity (primary outcome). Secondary outcomes include disability (key secondary), back pain intensity, quality of life, participants' perceived global effect, work absenteeism and health utilisation. Information about medication usage and tolerability are also collected. Outcomes are collected over one year (weeks 2, 4, 8, 12, 26 and 52). Double data entry will be conducted for primary and key secondary outcomes. Other outcomes will be checked using a risk-based approach. Analyses will be consistent with the intention-to-treat principle. Statistical tests will be two-tailed with a p value <0.05 considered significant. Group allocation will remain masked until analyses and interpretation are finalised. Repeated-measure linear mixed models will assess the effect of treatment (pregabalin versus placebo) on primary and secondary outcomes at all time points. Fixed effects will include group allocation, visit as a categorical variable and the interaction between group and visit. Covariates will include baseline leg pain and symptom duration, with an interaction term between baseline leg pain and visit. Pairwise differences between groups will be tested at weeks 8 and 52. The number of serious adverse events and adverse events will be reported, and the proportion of patients per group who have at least one event will be compared using Fisher's exact test. An economic evaluation will be conducted if there is a treatment effect on the primary outcome at week 8. A subgroup analysis will assess whether presenting features of neuropathic pain at baseline modify the treatment effect of leg pain at week 8. DISCUSSION: This statistical analysis plan provides detailed methodology for the analysis of the PRECISE study, which aims to deliver much needed evidence about effective and affordable management of sciatica. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ACTRN12613000530729. Registered 13 May 2013).

Pre- and postoperative evaluation of patients with lumbosacral disc herniation by neurophysiological and clinical assessment.

STUDY DESIGN: The application of complex neurophysiological examination including motor evoked potentials (MEP) for pre- and postoperative evaluation of patients experiencing acute sciatica. OBJECTIVE: The assessment of sensitivity and specificity of needle electromyography, MEP, and H-reflex examinations. The comparative analysis of preoperative and postoperative neurophysiological examination. SUMMARY OF BACKGROUND DATA: In spite of the fact that complex neurophysiological diagnostic tools seem to be important for interpretation of incompatible results of neuroimaging and clinical examination, especially in the patients qualified for surgical treatment, their application has never been completely analyzed and documented. METHODS: Pre- and postoperative electromyography, electroneurography, F-waves, H-reflex, and MEP examination were performed in 23 patients with confirmed disc-root conflict at lumbosacral spine. Clinical evaluation included examination of sensory perception for L5-S1 dermatomes, muscles strength with Lovett's scale, deep tendon reflexes, pain intensity with visual analogue scale, and straight leg raising test. RESULTS: Sensitivity of electromyography at rest and MEP examination for evaluation of L5-S1 roots injury was 22% to 63% and 31% to 56% whereas specificity was 71% to 83% and 57% to 86%, respectively. H-reflex sensitivity and specificity for evaluation of S1 root injury were 56% and 67%, respectively. A significant improvement of root latency parameter in postoperative MEP studies as compared with preoperative was recorded for L5 (P = 0.039) and S1 root's levels (P = 0.05). CONCLUSION: The analysis of the results from neurophysiological tests together with neuroimaging and clinical examination allow for a precise preoperative indication of the lumbosacral roots injury and accurate postoperative evaluation of patients experiencing sciatica. LEVEL OF EVIDENCE: 3.

Clinical course, characteristics and prognostic indicators in patients presenting with back and leg pain in primary care. The ATLAS study protocol.

BACKGROUND: Low-back related leg pain with or without nerve root involvement is associated with a poor prognosis compared to low back pain (LBP) alone. Compared to the literature investigating prognostic indicators of outcome for LBP, there is limited evidence on prognostic factors for low back-related leg pain including the group with nerve root pain. This 1 year prospective consultation-based observational cohort study will describe the clinical, imaging, demographic characteristics and health economic outcomes for the whole cohort, will investigate differences and identify prognostic indicators of outcome (i.e. change in disability at 12 months), for the whole cohort and, separately, for those classified with and without nerve root pain. In addition, nested qualitative studies will provide insights on the clinical consultation and the impact of diagnosis and treatment on patients' symptom management and illness trajectory. METHODS: Adults aged 18 years and over consulting their General Practitioner (GP) with LBP and radiating leg pain of any duration at (n = 500) GP practices in North Staffordshire and Stoke-on-Trent, UK will be invited to participate. All participants will receive a standardised assessment at the clinic by a study physiotherapist and will be classified according to the clinically determined presence or absence of nerve root pain/involvement. All will undergo a lumbar spine MRI scan. All participants will be managed according to their clinical need. The study outcomes will be measured at 4 and 12 months using postal self-complete questionnaires. Data will also be collected each month using brief postal questionnaires to enable detailed description of the course of low back and leg pain over time. Clinical observations and patient interviews will be used for the qualitative aspects of the study. DISCUSSION: This prospective clinical observational cohort will combine self-reported data, comprehensive clinical and MRI assessment, together with qualitative enquiries, to describe the course, health care usage, patients' experiences and prognostic indicators in an adult population presenting in primary care with LBP and leg pain with or without nerve root involvement.

Swimming training and functional assessment of sciatic nociception in rats.

INTRODUCTION: The protective effect of exercise on individuals with peripheral neuropathy is controversial. OBJECTIVE: To assess the influence of physical training of moderate and progressive intensity on nociception of rats in an experimental sciatica model. MATERIALS AND METHODS: The study assessed 18 rats divided into the following three groups: control group (CG); low-intensity swimming group (LISG); progressive-time swimming group (PTSG). To meet the physical training protocol, the animals were placed in a water tank for six weeks, three alternate days per week. In LISG group, the animals swam ten minutes per session, and, in PTSG group, the animals began swimming for ten minutes, and had a ten-minute increase per week. In CG group, the animals swam less than one minute per day, only to get used to the water environment. After finishing the swimming training, the experimental sciatica model protocol was started with constrictive ligature of the sciatic nerve with chromic catgut. Nociception was assessed using the functional disability test, which measures, in a one-minute interval, the time during which the animal holds its hind paw (THHP) in a guarded position. Assessments were performed preoperatively, and on the third, sixth, and tenth post-operative (PO) days. RESULTS: All groups showed a significant increase in THHP on third, sixth, and tenth PO days, as compared to preoperative values. In CG, no significant change was observed in PO assessments, unlike what happened in LISG and PTSG groups. CONCLUSION: Exercise produced greater hyperalgesia.

Treinamento com natação sobre a avaliação funcional da nocicepção ciática em ratos / Swimming training and functional assessment of sciatic nociception in rats

INTRODUÇÃO: Existe certa controvérsia com relação ao efeito protetor do exercício em indivíduos com neuropatia periférica. OBJETIVO: Avaliar o treinamento físico, moderado e com intensidade progressiva, como fator infl uenciador da nocicepção em ratos submetidos a um modelo de ciatalgia. MATERIAIS E MÉTODOS: Foram utilizados 18 ratos, divididos em três grupos: Grupo-Controle (PL); Grupo Natação Baixa Intensidade (GNBI); Grupo Natação Tempo Progressivo (GNTP). Para a realização dos protocolos de treinamento, os animais foram colocados em tanque de água, durante 6 semanas, 3 dias da semana, sendo que para GNBI os animais realizavam 10 minutos de natação por dia, para GNTP os animais iniciaram com 10 minutos e tendo progressão de 10 minutos por semana. PL realizava menos de 1 minuto de natação, apenas para ambientalização. Após o treinamento foi realizado o modelo experimental de ciatalgia, com amarria por fio Catgut cromado. Para avaliação da nocicepção foi utilizado o Teste de Incapacidade Funcional, que mostra os valores de tempo de elevação da pata (TEP) em um minuto. As avaliações ocorreram antes da cirurgia, no 3º, 6º e 10º dias de pós-operatório (PO). RESULTADOS: Para todos os grupos, foi possível observar que houve aumento significativo dos valores no 3º, 6º e 10º dias de PO ao comparar com os valores do momento pré-cirurgia, mas, para o controle, não houve alteração significativa entre os momentos seguintes, fato que ocorreu para os grupos de natação. CONCLUSÃO: O exercício produziu maior hiperalgesia do que nos animais controle.

INTRODUCTION: The protective effect of exercise on individuals with peripheral neuropathy is controversial. OBJECTIVE: To assess the influence of physical training of moderate and progressive intensity on nociception of rats in an experimental sciatica model. MATERIALS AND METHODS: The study assessed 18 rats divided into the following three groups: control group (CG); low-intensity swimming group (LISG); progressive-time swimming group (PTSG). To meet the physical training protocol, the animals were placed in a water tank for six weeks, three alternate days per week. In LISG group, the animals swam ten minutes per session, and, in PTSG group, the animals began swimming for ten minutes, and had a ten-minute increase per week. In CG group, the animals swam less than one minute per day, only to get used to the water environment. After finishing the swimming training, the experimental sciatica model protocol was started with constrictive ligature of the sciatic nerve with chromic catgut. Nociception was assessed using the functional disability test, which measures, in a one-minute interval, the time during which the animal holds its hind paw (THHP) in a guarded position. Assessments were performed preoperatively, and on the third, sixth, and tenth post-operative (PO) days. RESULTS: All groups showed a significant increase in THHP on third, sixth, and tenth PO days, as compared to preoperative values. In CG, no significant change was observed in PO assessments, unlike what happened in LISG and PTSG groups. CONCLUSION: Exercise produced greater hyperalgesia.

A modified Roland-Morris disability scale for the assessment of sciatica.

BACKGROUND: The Roland-Morris disability scale (RMS) for disability secondary to low back pain is a validated and popular instrument in clinical practice and research. We have made a simple modification to the questionnaire to increase sensitivity to sciatica (RMS-L) and validated this in patients with lumbar disc prolapse and radiculopathy. METHODS: The original RMS and modified RMS-L were prospectively administered to 203 patients presenting with lumbar radiculopathy and intervertebral disc prolapse demonstrated on MRI. Scores at pre-operative assessment and follow-up at 3 months and 12-24 months were compared against visual analogue scores (VAS) and Short Form 36 generic health domains. FINDINGS: Correlation between RMS-L and VAS leg pain was significantly greater than between original RMS and VAS leg pain pre-operatively (r = 0.57 vs. 0.17, p < 0.001) and at 3 months follow-up (r = 0.78 vs. 0.49, p < 0.001). Conversely, correlation between RMS and VAS back pain was significantly higher (r = 0.58 vs. 0.15, p < 0.001). Compared with RMS, at pre-operative assessment, RMS-L showed greater correlation with SF-36 physical function (PF; r = -0.57 vs. -0.32, p < 0.001) and bodily pain (r = -0.58 vs. -0.35, p < 0.001). Similarly, the change in PF to 3 months follow-up showed significantly higher correlation with change in RMS-L compared with the change in RMS (r = -0.60 vs. -0.37, p < 0.001). Effect sizes were good for RMS-L (1.19-1.24) but only moderate for RMS (0.69-0.79). CONCLUSIONS: The original and modified RMS can discriminate disability due to low back pain and sciatica, respectively. Separate assessment of these symptoms and their contribution to functional impairment is useful in assessing suitability for surgery and predicting outcome.

Physical therapy plus general practitioners' care versus general practitioners' care alone for sciatica: a randomised clinical trial with a 12-month follow-up.

A randomised clinical trial in primary care with a 12-months follow-up period. About 135 patients with acute sciatica (recruited from May 2003 to November 2004) were randomised in two groups: (1) the intervention group received physical therapy (PT) added to the general practitioners' care, and (2) the control group with general practitioners' care only. To assess the effectiveness of PT additional to general practitioners' care compared to general practitioners' care alone, in patients with acute sciatica. There is a lack of knowledge concerning the effectiveness of PT in patients with sciatica. The primary outcome was patients' global perceived effect (GPE). Secondary outcomes were severity of leg and back pain, severity of disability, general health and absence from work. The outcomes were measured at 3, 6, 12 and 52 weeks after randomisation. At 3 months follow-up, 70% of the intervention group and 62% of the control group reported improvement (RR 1.1; 95% CI 0.9-1.5). At 12 months follow-up, 79% of the intervention group and 56% of the control group reported improvement (RR 1.4; 95% CI 1.1; 1.8). No significant differences regarding leg pain, functional status, fear of movement and health status were found at short-term or long-term follow-up. At 12 months follow-up, evidence was found that PT added to general practitioners' care is only more effective regarding GPE, and not more cost-effective in the treatment of patients with acute sciatica than general practitioners' care alone. There are indications that PT is especially effective regarding GPE in patients reporting severe disability at presentation.

Factors associated with early opioid prescription among workers with low back injuries.

UNLABELLED: Prescription of opioids for nonmalignant musculoskeletal pain has increased substantially in recent years, but there is little information on the incidence of, or factors associated with, such prescription for work-related back pain. In a prospective cohort study (N = 1,067), we examined associations between worker sociodemographic and other characteristics and opioid prescription within six weeks of the first medical visit for workers' compensation claims for work loss due to back injury. We examined administrative, pharmacy, and worker-reported data. In bivariate logistic regression models, Hispanics were less likely than non-Hispanic whites to receive opioid prescriptions, and very high body mass index, daily tobacco use, greater pain and physical disability, pain radiating below the knee, injury severity categorizations (from medical records) of major sprain and radiculopathy, and worse mental health were associated with opioid prescription. Adjusting for demographics, pain intensity, and physical disability, opiate prescription was significantly associated with daily tobacco use, pain radiating below the knee, and injury severity categories (major sprain and radiculopathy). Knowledge of worker characteristics associated with early opioid prescription may be useful in future studies of the role of early pain treatment in influencing subsequent course of pain and disability among workers with back injuries. PERSPECTIVE: Little is known about patient characteristics that may influence physicians' decisions concerning prescription of opioids for acute back pain. Not surprisingly, workers with more severe back injuries are more likely to be prescribed opioids, but reasons for prescription disparities based on ethnicity and tobacco use warrant further study.

Indomethacin blocks the nucleus pulposus-induced effects on nerve root function. An experimental study in dogs with assessment of nerve conduction and blood flow following experimental disc herniation.

Inflammatory mechanisms have been suggested to be involved in the basic pathophysiologic events leading to nerve root injury after local application of nucleus pulposus. To assess if these nucleus pulposus-induced effects could be blocked by anti-inflammatory treatment, 41 dogs were exposed to either incision of the L6-7 disc to induce experimental disc herniation with (n=12) or without (n=14) indomethacin treatment per os (5 mg/kg per day), and no incision with (n=5) or without (n=10) indomethacin. Intraneural blood flow and nerve conduction velocity were assessed after 7 days to evaluate the degree of nerve injury. Disc incision induced a reduction in nerve root and dorsal ganglion blood flow as well as nerve function, similarly to previous studies. However, simultaneous treatment with indomethacin efficiently blocked the negative effects on both blood flow and nerve conduction but had no effects per se. The present study thus indicates that inflammatory mechanisms may be of relevance in the pathophysiology of nucleus pulposus-induced nerve root injury and thereby also for sciatica.

[Criteria validation of the Roland Morris questionnaire. A Danish translation of the international scale for the assessment of functional level in patients with low back pain and sciatica]. / Kriterievalidering af Roland Morris-spørgeskemaet. Et oversat internationalt skema til vurdering af aendringer i funktionsniveau hos patienter med laendesmerter og iskias.

INTRODUCTION: The main concern of patients with low back pain is the functional limitation which the symptoms cause. Therefore it is important to find a valid tool by means of which their functional level can be assessed. The aim of this study was to validate the first Danish translation of the Roland Morris Questionnaire (RMQ), which evaluates the functional level of activity of patients with low back pain and possible sciatica. The RMQ was compared with the functional scale of a Danish functional and pain level questionnaire, The Low Back Pain Rating Scale (RS), and the functional scale (PF) of the SF-36. MATERIAL AND METHODS: Independently, three professionals made a retroversion of the RMQ. Then 135 patients with lumbar disc herniation completed the RMQ, RS and the SF-36. The patients comprised 47% women and 53% men with an average age of 43 years. RESULTS: A significant correlation between the RMQ and the other two questionnaires was found. RMQ-RS; r = 0.89, p < or = 0.001, RMQ-PF (SF-36); r = -0.88 p < or = 0.001. A Chronbach Alpha showed a value of 0.94 (scale 0-1). Differences in scores between the three questionnaires were within the 95% limits of agreement. The average RMQ score was 10% higher than the score of RS and PF (SF-36). CONCLUSION: According to this study the RMQ can be used as a valid tool in the assessment of the functional level of patients with lumbar pain and previous lumbar herniation. Due to the fact that the questionnaire is fast and easy to complete, it is valid, reliable and sensitive and widely used internationally. We recommend the questionnaire to be used as a supplement to the clinical examination both in clinical practice and in research.

Patient-oriented assessment of back pain in pregnancy.

Back pain is a common symptom in women during the last period of pregnancy. Only a few studies using validated patient-oriented tools have been undertaken on this topic. We report on a multicenter study on back pain in women during the last period of pregnancy, which involved seven Italian institutions. Seventy-six women in their 8th and 9th months were studied using the Italian validated version of the Roland questionnaire -- a disease-specific patient-oriented tool for low back pain. Sixty-two percent of the women had gone through at least one previous pregnancy, and clinical data concerning both the period before all pregnancies and the period before the current pregnancy were acquired. The study found that 31% of the women had no back pain symptoms (Roland score 0), 40% scored from 1 to 4, 21% scored from 5 to 10, and 8% scored more than 10. With regard to the predictive factor, history of back pain and sciatica before the pregnancy were found to be associated with occurrence of back pain symptoms during pregnancy. Unexpectedly, our results showed that male sex of the fetus seems to be related to occurrence of back pain symptoms during pregnancy. However, back pain was not associated with having gone through previous pregnancies, nor was the Roland score related to the weight before pregnancy or to increment of weight during pregnancy. Evaluation of the patient's perspective made it possible to identify predictive factors for occurrence of back pain, thereby furnishing important information for the clinical approach to pregnancy.

The Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack) Study: baseline data.

STUDY DESIGN: Prospective cohort study of randomly selected Veterans Affairs (VA) outpatients. OBJECTIVE: To determine the prevalence of magnetic resonance imaging (MRI) findings in the lumbar spine among persons without current low back pain or sciatica and to examine which findings are related to age or previous back symptoms. SUMMARY OF BACKGROUND INFORMATION: Previous studies of patients without low back pain have not explored the possible association of various MRI findings to past symptoms. METHODS: We randomly selected an age-stratified sample of subjects without low back pain in the past 4 months from clinics at a VA hospital. We collected information on demographics, comorbidity, functional status, and quality of life. MR images were obtained using a standardized protocol through each of the five lumbar disc levels. RESULTS: Of 148 subjects, 69 (46%) had never experienced low back pain. There were 123 subjects (83%) with moderate to severe desiccation of one or more discs, 95 (64%) with one or more bulging discs, and 83 (56%) with loss of disc height. Forty-eight subjects (32%) had at least one disc protrusion and 9 (6%) had one or more disc extrusions. CONCLUSION: Many MR imaging findings have a high prevalence in subjects without low back pain. These findings are therefore of limited diagnostic use. The less common findings of moderate or severe central stenosis, root compression, and extrusions are likely to be diagnostically and clinically relevant.

Periradicular infiltration for sciatica: a randomized controlled trial.

STUDY DESIGN: A randomized, double-blind trial was conducted. OBJECTIVES: To test the efficacy of periradicular corticosteroid injection for sciatica. SUMMARY OF BACKGROUND DATA: The efficacy of epidural corticosteroids for sciatica is controversial. Periradicular infiltration is a targeted technique, but there are no randomized controlled trials of its efficacy. METHODS: In this study 160 consecutive, eligible patients with sciatica who had unilateral symptoms of 1 to 6 months duration, and who never underwent surgery were randomized for double-blind injection with methylprednisolone bupivacaine combination or saline. Objective and self-reported outcome parameters and costs were recorded at baseline, at 2 and 4 weeks, at 3 and 6 months, and at 1 year. RESULTS: Recovery was better in the steroid group at 2 weeks for leg pain (P = 0.02), straight leg raising (P = 0.03), lumbar flexion (P = 0.05), and patient satisfaction (P = 0.03). Back pain was significantly lower in the saline group at 3 and 6 months (P = 0.03 and 0.002, respectively), and leg pain at 6 months (13.5, P = 0.02). Sick leaves and medical costs were similar for both treatments, except for cost of therapy visits and drugs at 4 weeks, which were in favor of the steroid injection (P = 0.05 and 0.005, respectively). By 1 year, 18 patients in the steroid group and 15 in the saline group underwent surgery. CONCLUSIONS: Improvement during the follow-up period was found in both the methylprednisolone and saline groups. The combination of methylprednisolone and bupivacaine seems to have a short-term effect, but at 3 and 6 months, the steroid group seems to experience a "rebound" phenomenon.

A critical assessment of clinical diagnosis of disc herniation in patients with monoradicular sciatica.

The diagnostic power or clinical parameters in the diagnosis of lumbar disc herniation in patients with monoradicular pain was evaluated in a prospective study with a 100% verification of the diagnosis. Eighty patients with monoradicular pain corresponding to the fifth lumbar or the first sacral nerve root were included. Pre-operatively a number of clinical parameters were recorded and compared to the intra-operative finding of a disc herniation. The parameters were analysed by receiver operating characteristic (ROC) curves. Results from the available literature were analysed by ROC curves for comparison. In 76% of the cases a disc herniation was discovered. The level of the disc herniation was correctly predicted in 93% of these cases by the location of the pain alone or supplemented by neurological signs. Apart from radicularly distributed pain, all parameters in the present study and in the literature had no or low diagnostic accuracy. Thus, in patients with monoradicular sciatica further clinical parameters do not add to the diagnosis of lumbar disc herniation.