Efficacy evaluation of Mongolian medical warm acupuncture for sciatica caused by lumbar disc herniation: a randomized, controlled, single-blind clinical trial.

OBJECTIVE: This study aimed to evaluate the short-term and long-term efficacy of Mongolian medical warm acupuncture for sciatica caused by lumbar disc herniation (LDH). PATIENTS AND METHODS: The patients diagnosed with sciatica caused by LDH were randomly divided into the warm acupuncture of the Mongolian medicine group (n = 42, warm acupuncture treatment), the sham acupuncture group (n = 38, sham acupuncture using blunt-tipped needles) and the conventional drug group (n = 40, ibuprofen sustained release capsule). All patients were treated for 4 weeks and followed up for 8 weeks. The visual analog scale for leg pain (VAS-LP), Mongolian medicine indicators (efficacy indicators), VAS for waist pain (VAS-WP) and the Mos 36-item short form health survey (SF-36) score were analyzed at baseline, after two-week treatment, after four-week treatment, at four-week follow-up and at eight-week follow-up. RESULTS: Warm acupuncture treatment significantly decreased the VAS-LP and VAS-WP scores of patients at treatment and follow-up (p < 0.05), and pain was improved compared to the conventional drug group and sham acupuncture group. The total effective rate was markedly higher in the warm acupuncture of the Mongolian medicine group compared with the conventional drug group at 8-week follow-up (p < 0.05), but sham acupuncture treatment resulted in no evident improvement in the Mongolian medicine indicators. Additionally, at treatment and follow-up, warm acupuncture of the Mongolian medicine group showed a significant increase in the physical function, physical role, body pain, and emotional and mental health role scores of the SF-36 survey compared with the sham acupuncture groups. CONCLUSIONS: Mongolian medical warm acupuncture effectively relieves leg and waist pain and improves the total therapeutic effect and the quality of daily life for patients with sciatica caused by LDH, with significant long-term efficacy. Our study provides a basis for warm acupuncture in the treatment of sciatica caused by LDH. Chinese Clinical Trial Registry ID: ChiCTR- INR-15007413.

Ischial osteochondroma as an unusual source of pregnancy-related sciatic pain: a case report.

BACKGROUND: While most cases of sciatica result from degenerative conditions of the low back, some cases result from conditions of the hip and pelvic region. Sciatica developing in relation to pregnancy or labor also presents unique considerations. CASE PRESENTATION: A 37-year-old African American woman with a history of hypertension and polycystic ovary syndrome presented to a chiropractor at a hospital-based outpatient clinic with a seven-week history of low back pain with radiation into the right lower extremity which began during labor. The chiropractor performed a brief trial of care, yet when the patient's symptoms worsened, ordered lumbar spine radiographs, followed by lumbar magnetic resonance imaging (MRI), which were both normal. The chiropractor then ordered hip radiographs, which were suggestive of ischial osteochondroma, and referred the patient to an orthopedic oncologist. MRI findings were compatible with an osteochondroma with associated adventitial bursitis and mass effect on the sciatic nerve. The patient initially chose conservative management with bursa aspiration and therapeutic injection. Despite initial relief, there was eventual return of symptoms. The patient elected to undergo surgical removal, with a positive outcome. CONCLUSION: The key distinguishing features that led to a diagnosis of osteochondroma in this case included attention to the patient-reported symptoms and history, worsening of symptoms despite conservative care, and lack of explanatory findings on lumbar imaging. This case highlights the benefit of evaluating the hip and pelvis when the clinical features of sciatica cannot be ascribed to a lumbar etiology. This case also illustrates the role of a chiropractor working in an integrative health system to facilitate timely imaging and referrals to resolve a challenging diagnosis.

Ma's bamboo-based medicinal moxibustion therapy of low back pain in lumbar disc herniation: study protocol for a randomized controlled trial.

BACKGROUND: Lumbar disc herniation (LDH) is a common and frequently occurring disease in clinics. Low back pain and sciatica are the presenting symptoms of LDH. To some extent, it can be considered that measures with the capability to improve low back pain or sciatica have the potential to treat LDH. Ma's bamboo-based medicinal moxibustion therapy can effectively reduce the degree of low back pain and has been widely used. Studies of small sample size have seen significant improvement on pain relief. The aim of this trial is to evaluate the clinical efficacy and safety of Ma's bamboo-based medicinal moxibustion therapy in the treatment of LDH low back pain. METHODS/DESIGN: The trial is a multicenter, randomized, parallel-group, non-inferiority study. Three hundred and twelve patients will be randomly assigned to a Ma's bamboo-based medicinal moxibustion group (n=156) and an acupuncture group (n=156). Patients in each group will receive treatment every day, 6 times a week, 12 times in total. Follow-up will be conducted 14 days after treatment. The primary outcome will be the visual analog scale(VAS) at baseline, after 6 times of treatment, end of treatment, and follow-up. The secondary outcomes will include Oswestry disability indexes (ODI), modified Japanese Orthopaedic Association low back pain (M-JOA) score, serum ß-endorphin (ß-EP), and serum substance P (SP). ß-EP and SP, as well as safety evaluation indexes (routine blood, liver, and kidney function and electrocardiogram), will be measure at baseline and after the end of treatment. The number, nature, and severity of adverse events will be recorded. DISCUSSION: The results of the trial will compare the efficacy of low back pain in LDH between Ma's bamboo-based medicinal moxibustion group and the acupuncture group and will be expected to make a systematic and objective evaluation of the clinical efficacy and safety of Ma's bamboo-based medicinal moxibustion therapy. TRIAL REGISTRATION: ChiCTR2000038725 . Registered on 29 September 2020.

Efficacy of acupuncture for sciatica: study protocol for a randomized controlled pilot trial.

BACKGROUND: Acupuncture is widely used for pain diseases while evidence of its efficacy for sciatica is insufficient. We aim to explore the feasibility and efficacy of acupuncture with different acupoint selecting strategies for sciatica induced by lumbar disc herniation. METHODS: This is a multicenter, three-arm, patient-assessor-blinded randomized controlled pilot trial. Ninety patients will be assigned randomly into 3 groups including disease-affected meridians (DAM) group, non-affected meridians (NAM) group, and sham acupuncture (SA) group in a 1:1:1 ratio. The trial involves a 4-week treatment along with follow-up for 22 weeks. The primary outcome is the change of leg pain intensity measured by the visual analogue scale (VAS) from baseline to week 4 after randomization. Secondary outcomes include functional status, back pain intensity, and quality of life. Adverse events will also be recorded. DISCUSSION: The results will inspire the optimal acupuncture strategy for sciatica and help establish a better design as well as power calculation for a full-scale study. TRIAL REGISTRATION: ChiCTR2000030680 (Chinese Clinical Trial Registry, http://www.chictr.org.cn , registered on 9 March 2020).

Efficacy and Safety of Acupuncture for Chronic Discogenic Sciatica, a Randomized Controlled Sham Acupuncture Trial.

OBJECTIVE: To evaluate the efficacy and safety of acupuncture for discogenic sciatica. DESIGN: Single-center, parallel, randomized controlled sham acupuncture trial. METHODS: Twelve sessions of acupuncture or sham acupuncture at the same traditional acupoints over four weeks. The primary outcome was change from baseline in weekly mean leg pain, measured by the visual analog scale (VAS) over the four-week treatment period. The secondary outcomes were determined by the change from baseline in mean VAS scores for leg pain, VAS scores for low back pain, Oswestry Disability Index (ODI) scores, and 36-Item Short Form Health Survey (SF-36) scores. Patients were followed for 28 weeks. RESULTS: Forty-six patients were enrolled in this study between June 2017 and January 2018, of which 23 were in the acupuncture group and 23 were in the sham acupuncture group. The between-group difference in weekly mean leg pain measured by the VAS over the four-week treatment period was -7.28 mm (95% confidence interval = -13.76 to -0.80, P = 0.029), which is larger than the minimum clinically important difference of 5 mm. The between-group differences in mean VAS scores for low back pain, ODI scores, and SF-36 scores were not significant in the study period (P > 0.05 for all). The proportion of acupuncture-related adverse events was 4.3%, and all adverse events were mild and transient. CONCLUSIONS: Twelve sessions of acupuncture showed short-term clinical benefits in relieving the symptoms of leg pain for patients with chronic discogenic sciatica compared with sham acupuncture. Acupuncture is safe in treating chronic discogenic sciatica. Further studies with larger sample sizes, a longer treatment period, and long-term follow-up should be conducted to verify these results.

Effect and neurophysiological mechanism of acupuncture in patients with chronic sciatica: protocol for a randomized, patient-assessor blind, sham-controlled clinical trial.

BACKGROUND: Sciatica is a relatively frequent illness that easily becomes a chronic and relapsing condition. Although numerous systematic reviews have analyzed various therapies for sciatica, the validity of their included studies is limited. Considering the limitations of conventional treatment options for sciatica, acupuncture is a possible option; however, evidence supporting its efficacy and mechanism in patients with sciatica is lacking. The aim of this proposed protocol is to investigate the effect and neurophysiological mechanism of acupuncture in patients with chronic sciatica. METHODS/DESIGN: This study is a randomized, patient-assessor blind, two-arm, parallel, non-penetrating, sham-controlled clinical trial. Eligible participants will include adults (aged 19-70 years old) with a clinical diagnosis of chronic sciatica (40 mm or more of a 100-mm visual analog scale (VAS) for bothersomeness) blinded to the treatment received. Patients will be randomly allocated into the acupuncture treatment group (manual acupuncture plus electroacupuncture (EA), n = 34) or the sham acupuncture control group (sham acupuncture plus placebo EA without electrical stimulation, n = 34). Groups will receive treatment twice a week for a total of eight sessions over 4 weeks. Functional magnetic resonance imaging will be implemented at baseline and endpoint to investigate the mechanism of acupuncture. The primary outcome measure is the VAS for bothersomeness and secondary outcomes include the VAS for pain intensity, Oswestry Disability Index, EuroQol 5-Dimension, Coping Strategy Questionnaire, Beck's Depression Inventory, and State-Trait Anxiety Inventory. Adverse events will be assessed at every visit. DISCUSSION: The results of this trial (which will be available in 2020) should provide important clinical evidence for the effect of acupuncture and demonstrate how acupuncture can be helpful for the treatment of chronic sciatica. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03350789 . Registered on 15 November 2017.

Healthcare utilisation of pregnant women who experience sciatica, leg cramps and/or varicose veins: A cross-sectional survey of 1835 pregnant women.

BACKGROUND: Common discomforts of pregnancy experienced in the lower extremity include sciatica, leg cramps and varicose veins. Whilst research attention has focused on aetiology and outcomes, the health service utilisation of pregnant women suffering from these complaints has been largely overlooked. AIM: To examine the health status and health service utilisation profile of pregnant women experiencing sciatica, leg cramps or varicose veins. METHODS: Linear and logistic regression was applied to a cross-sectional survey of a pregnant women drawn from the 1973 to 1978 cohort (aged 31-36 years in 2009), of the Australian Longitudinal Study on Women's Health (n=1835). Participant's demographics, health status and health service utilisation were compared for all three complaints based upon three subgroups (yes, sought help; yes, did not seek help; no). FINDINGS: A number of women experienced sciatica (22.1%), leg cramps (18.2%) or varicose veins (9.4%). Of these, a greater proportion of women with sciatica (79.3%) or varicose veins (71.5%) sought help for their condition compared with women with leg cramps (46.7%). Comparisons between women with the conditions of interest who did seek help and those who did not only found that women with a university degree were 0.29 (95% CI: 0.10, 0.85) times less likely to seek help for their condition compared to women with a school only education. CONCLUSION: Further research examining all health seeking behaviour and treatment use of pregnant women who experience lower extremity problems is required in order to facilitate safe, effective and coordinated maternity care to further support these women during pregnancy.

Effects of Shinbaro pharmacopuncture in sciatic pain patients with lumbar disc herniation: study protocol for a randomized controlled trial.

BACKGROUND: Lumbar disc herniation is a major cause of sciatica and low back pain and imposes a heavy burden on both individual and society. While use of pharmacopuncture, a combined form of acupuncture and herbal medicine, for lumbar disc herniation is widespread in Korea and China, there is a paucity of research. METHODS/DESIGN: This study is the protocol for a three-armed, randomized, patient, physician, and assessor-blinded controlled pilot study. Sixty patients with severe non-acute sciatic pain diagnosed with lumbar disc herniation (NRS ≥ 5, onset between 4 weeks and 6 months) will be recruited and randomized 20 each to the Shinbaro pharmacopuncture (pharmacopuncture with acupuncture), acupuncture, and usual care groups, respectively. The 2 acupuncture groups will receive 2 sessions/week of acupuncture alone or with pharmacopuncture for 4 weeks (total 8 sessions), and the usual care group will receive conventional medication 2-3 times/day and physical therapy 2 sessions/week over 4 weeks (total 8 sessions). The initial acupuncture physician will administer acupuncture at 5 acupoints (GB30, BL40, BL25, BL23, GB34) in the 2 acupuncture groups, and mark an additional acupoint. A second acupuncture physician will administer pharmacopuncture to the marked acupoint in the pharmacopuncture group, and acupuncture in the acupuncture group during acupuncture needle retention. The second physician will administer acupuncture and pharmacopuncture in a similar manner in terms of advice and manual stimulation to maintain patient-blinding, treat the patient out of view of the initial physician, remove the additional acupuncture needle immediately, and cover the area with adhesive bandage to maintain physician-blinding. The primary endpoint will be at 5 weeks post-randomization, and the primary outcome will be Visual Analog Scale (VAS) of sciatic pain. Secondary outcomes will be VAS of low back pain, Numeric Rating Scale (NRS) of low back pain and sciatic pain, ODI, SF-36, EQ-5D, and PGIC. Post-treatment evaluations will take place 5, 7, 9, and 12 weeks after randomization. DISCUSSION: This trial will evaluate the comparative clinical effectiveness of pharmacopuncture for severe non-acute sciatic pain patients diagnosed with lumbar disc herniation with usual care of conventional medicine and that of Korean medicine (acupuncture), monitor its safety, and serve as basis for a large-scale, multicenter trial. TRIAL REGISTRATION: ClinicalTrials.gov NCT02384928 , registered 27 February 2015.

Trigger point-related sympathetic nerve activity in chronic sciatic leg pain: a case study.

Sciatica has classically been associated with irritation of the sciatic nerve by the vertebral disc and consequent inflammation. Some authors suggest that active trigger points in the gluteus minimus muscle can refer pain in similar way to sciatica. Trigger point diagnosis is based on Travel and Simons criteria, but referred pain and twitch response are significant confirmatory signs of the diagnostic criteria. Although vasoconstriction in the area of a latent trigger point has been demonstrated, the vasomotor reaction of active trigger points has not been examined. We report the case of a 22-year-old Caucasian European man who presented with a 3-year history of chronic sciatic-type leg pain. In the third year of symptoms, coexistent myofascial pain syndrome was diagnosed. Acupuncture needle stimulation of active trigger points under infrared thermovisual camera showed a sudden short-term vasodilatation (an autonomic phenomenon) in the area of referred pain. The vasodilatation spread from 0.2 to 171.9 cm(2) and then gradually decreased. After needling, increases in average and maximum skin temperature were seen as follows: for the thigh, changes were +2.6°C (average) and +3.6°C (maximum); for the calf, changes were +0.9°C (average) and +1.4°C (maximum). It is not yet known whether the vasodilatation observed was evoked exclusively by dry needling of active trigger points. The complex condition of the patient suggests that other variables might have influenced the infrared thermovision camera results. We suggest that it is important to check if vasodilatation in the area of referred pain occurs in all patients with active trigger points.

Low back pain radiating to the leg: an atypical cause.

This study reports the case of a 47-year old female with low back pain radiating to groin and anterior regions of the left thigh and leg. At symptoms onset, electromyography showed left L3-L4 radiculopathy, and nuclear magnetic resonance revealed disc protrusion at the same level with impingement of the spinal nerve root. The clinical symptoms were ascribed to lumbar disco-radicular conflict. The patient underwent steroidal anti-inflammatory treatment with epidural steroid injections, chiropractic spinal manipulations and rehabilitation program, with no relief. Thirteen months after the onset of pain, a computed tomography of sacroiliac joints showed osteolytic lesion in the iliac bone of left joint, and a bone scintigraphy highlighted foci of intense uptake at left iliac bone and left proximal extremity of the femur. The bone biopsy and pathological examinations showed findings consistent with large B-cell non-Hodgkin lymphoma. This case report highlights the fact that in making differential diagnosis of low back pain radiating to the leg we have to consider the rare possibility that pain can be due to non-Hodgkin lymphoma that involves simultaneously the iliac bone and proximal extremity of the femur.

Management of low back pain in general practice - is it of acceptable quality: an observational study among 25 general practices in South Tyrol (Italy).

BACKGROUND: There are several guidelines dealing with the management of low back pain (LBP), but only few studies on the quality of care provided within General Practices as judged against those guidelines.The objective of this study is to analyse the management of LBP in Italian General Practice and compare it with guideline recommendations. METHODS: In this observational study, all patients visiting their General Practitioners (GPs) for treatment of LBP within a 8-week period were monitored for at least four weeks with regard to symptoms and diagnostic and therapeutic interventions. Management of LBP was judged by pre-defined quality indicators based on guideline recommendations. RESULTS: Twenty-five of 114 eligible GPs participated in the study, representing a total of 43,012 registered patients. Of the 475 patients complaining of LBP and monitored for four weeks, 55.8% were diagnosed as having acute lumbar pain, 13.5% chronic lumbar pain, 17.1% acute sciatica, and 12.6% chronic sciatica; 76.0% underwent no technical investigations, 21.7% underwent x-rays, 5.5% MRI and 4% CT scans; 20.4% were referred to secondary care; 93.3% of all patients received some medication. In those receiving a medication, in 88.3% it was an NSAID, in 6.3% Paracetamol, in 10.4% Paracetamol combined with Codeine, and in 9% a muscle relaxants. When physiotherapy was prescribed (17,1%), it was mostly massage. Hardly more than 50% of GPs (partially) followed locally established guidelines, while the remainder seemed not to follow guidelines at all. CONCLUSIONS: Our study reveals gross deviations of GP management of LBP from current guidelines and points to two different types of deviators: those who partially follow guidelines, and those who do not follow them at all. Further research should evaluate whether these two types of deviation are best addressed by different foci of education, i.e. on knowledge versus attitudes, respectively.

Surgeon attitudes toward nonphysician screening of low back or low back-related leg pain patients referred for surgical assessment: a survey of Canadian spine surgeons.

STUDY DESIGN: Questionnaire survey. OBJECTIVE: To explore spine surgeons' attitudes toward the involvement of nonphysician clinicians (NPCs) to screen patients with low back or low back-related leg pain referred for surgical assessment. SUMMARY OF BACKGROUND DATA: Although the utilization of physician assistants is common in several healthcare systems, the attitude of spine surgeons toward the independent assessment of patients by NPCs remains uncertain. METHODS: We administered a 28-item survey to all 101 surgeon members of the Canadian Spine Society, which inquired about demographic variables, patient screening efficiency, typical wait times for both assessment and surgery, important components of low back-related complaints history and examination, indicators for assessment by a surgeon, and attitudes toward the use of NPCs to screen patients with low back and leg pain referred for elective surgical assessment. RESULTS: Eighty-five spine surgeons completed our survey, for a response rate of 84.1%. Most respondents (77.6%) were interested in working with an NPC to screen patients with low back-related complaints referred for elective surgical assessment. Perception of suboptimal wait time for consultation and poor screening efficiency for surgical candidates were associated with greater surgeon interest in an NPC model of care. We achieved majority consensus regarding the core components for a low back-related complaints history and examination, and findings that would support surgical assessment. A majority of respondents (75.3%) agreed that they would be comfortable not assessing patients with low back-related complaints referred to their practice if indications for surgery were ruled out by an NPC. CONCLUSION: The majority of Canadian spine surgeons were open to an NPC model of care to assess and triage nonurgent or emergent low back-related complaints. Clinical trials to establish the effectiveness and acceptance of an NPC model of care by all stakeholders are urgently needed.

Utilidad de un medicamento biorregulador en el tratamiento de la pseudociática por un síndrome del piriforme en corredores de larga distancia / Utility of a inflammation bio-regulator drug in treatment of pseudosciatica for piriformis syndrome in long distance runners

Introducción y objetivo: El objetivo del estudio es demostrar si la inclusión de un medicamento biorregulador de la inflamación (Traumeel S®) en el protocolo médico-manual aconsejado para el síndrome piramidal, mejora la clínica y acorta el proceso de recuperación funcional en corredores fondistas. Material y métodos: Se estudian dos grupos de pacientes(31/31), aplicándose al primero tratamiento manual con masaje, liberación miofascial, estiramientos post-isométricos y técnicas de energía muscular; y al segundo, el mismo protocolo junto a inyecciones semanales de Traumeel S®, en un seguimiento de 10 semanas. Se evalúa el dolor mediante cuatro pruebas exploratorias, y la percepción subjetiva del paciente en una EVA. Resultados: Se analizó la evolución de 62 pacientes, 50%hombres con edad media de 42,8 años (IC95% 41,6-44).Observamos en los pacientes tratados con Traumeel S®: una proporción menor de visitas con dolor (p<0, 0001), y un promedio de dos visitas menos con dolor (14 días) en todos los test evaluados. El tiempo hasta la desaparición del dolor en todos los test, fue significativamente menor (mediana de supervivencia de 6 semanas (IC95% 5,7-6,3) frente a 8 semanas (IC95% 6,8-9,2) en el grupo control (p<0,0001). La valoración del dolor por el paciente fue significativamente mejor en el grupo tratado con Traumeel S® (p<0, 0001). No se observaron acontecimientos adversos. Conclusión: Se demuestra que el tratamiento con Traumeel S® reduce el tiempo con dolor en hasta dos semanas. Al disminuirla inflamación en la articulación sacroilíaca, y en su inserción tendinosa conseguimos una resolución más rápida del espasmo y por tanto del cuadro clínico (AU)

Background: The objective of the study is demonstrate if the inclusion of a bio-regulator drug for inflammation (TraumeelS®) in the medical-manual protocol recommended for the pyramidal syndrome, improves the clinic and shortens the functional recovery process in long distance runners. Methods: Two groups of patients are studied (31/ 31), applying manual treatment with massage, miofascial liberation, postisometric stretches and technics of muscular energy; and to the second group, the same protocol and weekly injections of Traumeel S®, in a 10 weeks follow up. The patient’s pain is evaluated with four exploratory tests, and the subjective perception in a Visual Analogic Scale (VAS).Results: 50% of the patients were male with mean age of 42.8years (CI95% 41,6-44). In patients treated with Traumeel S®we observed: lower proportion of visits with pain (p< 0,0001),and an average of two visits less with pain (14 days) in all the evaluated test. Time until the disappearance of the pain in all the test, was significantly lower: median of survival, 6 weeks (CI95% 5,7-6,3), versus 8 weeks (CI95% 6,8-9,2) in the control group (p< 0,0001). The pain evaluation by the the patient was significantly better in the group treated with Traumeel S® (p<0,0001). No adverse events were observed. Conclusion: We observe that the treatment with Traumeel S® reduces the time with pain in up to two weeks. Upon diminishing the inflammation in the sacro-iliac articulation, and in its tendinous insertion, we got a quicker resolution of the spasm and therefore of the clinical manifestations (AU)

Validity of the straight-leg raise test for patients with sciatic pain with or without lumbar pain using magnetic resonance imaging results as a reference standard.

OBJECTIVE: The aim of this retrospective study was to assess validity of the straight-leg raise (SLR) test using magnetic resonance imaging (MRI) results as a reference standard in a group of patients with L4-L5 and L5-S1 lumbar-herniated disks and sciatic pain. The relationship between diagnostic accuracy of this test, age classes, and grade of lumbar disk displacement was investigated. METHODS: The charts of 2352 patients with sciatic pain with/without lumbar pain were examined. Results of the SLR were then compared with previous spinal MRI. A 2 × 2 contingency table was created, and analysis of sensitivity, specificity, positive and negative predictive values, diagnostic odds ratio, likelihood ratio (LR), and receiver operating characteristic (ROC) curve was carried out. Homogeneous age classes were created to compare them statistically. RESULTS: Magnetic resonance imaging findings showed lumbar disk herniation (LDH) in 1305 patients. Of these subjects, 741 were positive on SLR testing. Sensitivity was 0.36, whereas specificity was 0.74. Positive and negative predictive values were 0.69 and 0.52, respectively. Positive LR was 1.38, and negative LR was 0.87. Diagnostic odds ratio was 1.59, and ROC analysis showed an area under the curve (AUC) of 0.596. The AUC decreased from 0.730 in the 16- to 25-year subgroup to 0.515 in the 76- to 85-year subgroup. Similar results were obtained in subjects with LDH and nerve root compression. CONCLUSIONS: Our results indicate low accuracy of the SLR in diagnosis of LDH if compared with MRI results. The discriminative power of the SLR seemed to decrease as age increased; thus, positive and negative results may be less conclusive in older patients.

Sciatica: what the rheumatologist needs to know.

Sciatica is a set of symptoms rather than a specific diagnosis, and is caused by a herniated lumbar disc in the vast majority of cases. The most important symptom is lower limb pain radiating below the knee and into the foot and toes. The clinical course of acute sciatica is generally favorable, with most pain and related disability improving within 2-4 weeks with or without treatment. Diagnosis mainly involves history taking and physical examination. Imaging is warranted if there is evidence of an underlying pathology other than disc herniation, such as infection or malignancy, and in patients with severe symptoms that do not improve after 6-8 weeks of conservative treatment. MRI is the preferred imaging modality, as it can visualize soft tissues better than CT and does not expose the patient to ionizing radiation. Conservative treatment is generally the first-line option in patients with sciatica; however, the currently available evidence does not show any intervention--including a broad range of conservative and surgical approaches--to have clearly superior outcomes. Thus, patient preference seems to be an important factor in the clinical management of sciatica.

Repeat upright positional magnetic resonance imaging for diagnosis of disorders underlying chronic noncancer lumbar pain.

OBJECTIVE: Cases of chronic noncancer pain are both the most frequent and the most difficult that the spine care professional is called upon to treat. We use this case to illustrate the potential effectiveness of repeat positional upright, weight-bearing magnetic resonance (MR) imaging to diagnose disorders and to detect changes in disorders. CLINICAL FEATURES: We present the case of a 35-year-old man referred to our neurosurgical clinic with complaints of chronic, noncancer lower back pain and right-greater-than-left sciatica. Traditional recumbent MR imaging had revealed degenerative disk disease at L5-S1 and a 2.2-mm (grade 1) degenerative spondylolisthesis. The patient had not improved after more than a year of conservative treatments and, moreover, had been prescribed opiates for pain management that were potentially masking changes in his condition. INTERVENTION AND OUTCOMES: After referral to our clinic, we ordered repeat lumbar MR imaging in an upright weight-bearing position (sitting) 14 months after the patient's recumbent MR imaging. The weight-bearing MR imaging revealed a 9.13-mm (grade 1) degenerative spondylolisthesis at L5-S1. The patient underwent arthrodesis. His leg pain and back were significantly and clinically improved. CONCLUSION: When patients with noncancer, lower back pain worsen, fail to improve, or require opiates to manage their pain, updated clinical diagnosis including repeat positional imaging may be an effective diagnostic strategy.

Diagnosis and management of piriformis syndrome: an osteopathic approach.

Piriformis syndrome is a neuromuscular condition characterized by hip and buttock pain. This syndrome is often overlooked in clinical settings because its presentation may be similar to that of lumbar radiculopathy, primary sacral dysfunction, or innominate dysfunction. The ability to recognize piriformis syndrome requires an understanding of the structure and function of the piriformis muscle and its relationship to the sciatic nerve. The authors review the anatomic and clinical features of this condition, summarizing the osteopathic medical approach to diagnosis and management. A holistic approach to diagnosis requires a thorough neurologic history and physical assessment of the patient based on the pathologic characteristics of piriformis syndrome. The authors note that several nonpharmacologic therapies, including osteopathic manipulative treatment, can be used alone or in conjunction with pharmacotherapeutic options in the management of piriformis syndrome.

Low intensity permanent magnets in the treatment of chronic lumbar radicular pain.

We assessed the pain-relieving efficacy of static magnetic fields produced by 200 Gauss (G) magnets compared with 50G magnets in a double-blind, randomized, two-phase crossover study in patients with chronic lumbar radicular pain. The surface field strengths of the magnets were 200 and 50G. Phase I included four random periods of two-week duration: two periods with 200G, one period with 50G, and one period of "no treatment." The magnets were positioned either vertically or horizontally in standard lumbosacral elastic corsets. Phase II consisted of two five-week periods with the most effective magnet from Phase I and its corresponding 50 or 200G device. The primary outcome was average daily leg pain score (0-10 scale) in each period of Phase II. Thirty-eight of 40 randomized patients completed Phase I, and 28 of 31 Phase II participants completed the study. In Phase I, pain scores did not differ significantly between 200 and 50G magnets. Phase II average leg pain scores tended to be lower with 200 vs. 50G magnets (3.2+/-2.1 for 200G vs. 3.9+/-2.2 for 50G magnets [P=0.08]) after excluding one unblinded patient. The relative treatment effect of the 200G magnets appeared to increase throughout the five-week period. Although these data cannot rule out a chance effect, the positive trends suggest that larger, longer-duration, sham-controlled trials with 200G magnets be considered in patients with chronic lumbar radicular pain.

Diagnosis and management of posttraumatic piriformis syndrome: a case study.

OBJECTIVE: The aim of this study is to describe the clinical management of a young male patient with sciatica symptoms that developed after an avulsion of the ischial tuberosity. This is a rare injury, but complications may occur. CLINICAL FEATURE: A 19-year-old patient developed sciatica 6 months after a football injury. The patient described his symptoms as a shooting pain from the buttock to the lateral part of the foot, along the back of his thigh and calf, sometimes accompanied by paresthesia. Physical examination showed restricted hip range of motion and a positive Bonnet's test. X-ray analysis revealed a bony overgrowth of the right ischial tuberosity. INTERVENTION AND OUTCOME: A treatment plan was designed to decrease the pain level, increase sacroiliac and lumbar joint mobility, and augment muscular extensibility. The patient received 20 treatments over a period of approximately 3 months. Complete recovery was observed 5 months later. CONCLUSION: Although many differential diagnoses were contemplated, it is most likely that changes in muscular tension and gait pattern, resulting from the ischial tuberosity avulsion, contributed to overuse of the piriformis muscle leading to a piriformis syndrome.

Interventions that increase or decrease the likelihood of a meaningful improvement in physical health in patients with sciatica.

BACKGROUND AND PURPOSE: The purpose of our study was to determine whether physical therapy interventions predicted meaningful short-term improvement in physical health for patients diagnosed with sciatica. SUBJECTS: We examined data from 1,804 patients (age: mean=52.1 years, SD=15.6 years; 65.7% female, 34.3% male) who had been diagnosed with sciatica and who had completed an episode of outpatient physical therapy. METHODS: Principal components factor analysis was used to define intervention categories from specific treatments applied during the plan of care. A nested-model logistic regression analysis identified intervention categories that predicted meaningful improvement in physical health. Meaningful improvement was defined as a change of 14 or more points on the Physical Component Scale-12 (PCS-12) summary score. RESULTS: Twenty-six percent (n=473) of patients had a meaningful improvement in physical health. Improvement was more likely in patients receiving joint mobility interventions (odds ratio [OR]=2.5, 95% confidence interval [CI]=1.5-4.4) or general exercise (OR=1.5, 95% CI=1.2-2.0). Patients who received spasm reduction interventions were less likely to improve (OR=0.77, 95% CI=0.60-0.98). DISCUSSION AND CONCLUSION: Physical therapists should emphasize the use of joint mobility interventions and exercise when treating patients with sciatica, whereas interventions for spasm reduction should be avoided.