Mauno Kurunlahti

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 three-year follow-up of lumbar spine endplate (modic) changes

Study Design. A longitudinal follow-up of Modic changes on magnetic resonance imaging (MRI). Objectives. To assess the prevalence and natural course Modic changes over a 3-year follow-up period. Summary of Background Data. Modic changes are bone marrow and endplate lesions visible on MRI. To the authors’ knowledge, no follow-up studies on their natural course have been published. Methods. The study population consisted of 60 unoperated sciatica patients 23 to 76 years of age. Baseline and 3-year lumbar MR images from L1–L2 through L5–S1 were analyzed independently by 2 radiologists and a consensus reading was performed. Results. At baseline, the prevalence of Modic changes was 23%. Seven discs had mixed Type I/II, and 63 Type II change. Changes typically occurred at L4–L5 and L5–S1, and associated positively with age (P = 0.009). Ten of 70 discs (14%) with Modic changes at baseline displayed another type at 3 years. Furthermore, the nonconverted changes increased significantly in size. The incidence of new Modic changes during the follow-up was 6% (13 of 230). Conclusions. Modic changes are common MRI findings in patients with degenerative lumbar disc disease. We found evidence that Modic Type II changes may be less stable than previously assumed.

Cost Effectiveness of Periradicular Infiltration for Sciatica : Subgroup Analysis of a Randomized Controlled Trial

Study Design. A subgroup analysis of a prospective, randomized controlled trial was performed. Objective. To describe the cost effectiveness of periradicular infiltration with steroid in subgroups of patients with sciatica. Summary of Background Data. A recent trial on periradicular infiltration indicated that a methylprednisolone–bupivacaine combination had a short-term effect, as compared with that of saline. This report describes the efficacy and cost effectiveness of steroid in subgroups of patients with sciatic. Methods. This study involved 160 patients with unilateral sciatica. Outcome assessments were leg pain (100-mm visual analog scale), disability on the Oswestry Low Back Disability Questionnaire, and the Nottingham Health Profile. Data on medical costs and sick leaves also were gathered. Patients were randomized for periradicular infiltration with either methylprednisolone–bupivacaine or saline. The adjusted between-group treatment differences at each follow-up assessment, the number of patients free of leg pain (responders, cutoff 75%), and efficacy by the area-under-the-curve method were calculated. For the cost-effectiveness estimate, the total costs were divided by the number of responders. The rate of operations in different subgroups was evaluated by Kaplan-Meier analysis. Results. In the case of contained herniations, the steroid injection produced significant treatment effects and short-term efficacy in leg pain and in Nottingham Health Profile emotional reactions. For symptomatic lesions at L3–L4–L5, steroid was superior to saline for leg pain, disability, and straight leg raising in the short term. By 1 year, steroid seemed to have prevented operations for contained herniations, costing

Association of Atherosclerosis with Low Back Pain and the Degree of Disc Degeneration

12,666 less per responder in the steroid group (P < 0.01). For extrusions, steroid seemed to increase the operation rate, and the steroid infiltration was more expensive, costing

Determinants of spontaneous resorption of intervertebral disc herniations

4445 per responder (P < 0.01). Conclusions. In addition to short-term effectiveness for contained herniations and lesions at L3–L4–L5, steroid treatment also prevented surgery for contained herniations. However, steroid was countereffective for extrusions. The results of the subgroup analyses call for a verification study.

Severity of symptoms and signs in relation to magnetic resonance imaging findings among sciatic patients.

STUDY DESIGN This was a cross-sectional observational study in which the abdominal aorta was evaluated for atheromatous lesions visible in computed tomographic scans in patients with and without low back pain. OBJECTIVES To evaluate whether patients with low back pain have more atherosclerosis in the abdominal aorta than patients without low back pain and whether the severity of atherosclerosis in the abdominal aorta correlates with the grade of disc damage. SUMMARY OF BACKGROUND DATA There are studies in which results indicate that insufficient blood supply may be a significant causative factor in disc degeneration. There are also studies in which smoking, one of the risk factors for arterial disease, has been correlated with low back pain. Calf pain has also been shown to correlate with low back pain. Results in a long-term follow-up study have further indicated an association between disc diseases and fatal ischemic heart disease. However, there seems to be only one postmortem study in which results show an association between atherosclerosis in the arteries of the lumbar area and disc diseases. METHODS Computed tomographic images of 29 patients with low back pain, who had been evaluated with computed tomographic discography for diagnostic purposes, were evaluated for the quantity of atherosclerotic calcifications visible on computed tomographic scans of the abdominal aorta. A similar evaluation was performed in an age- and sex-matched control group of 52 patients without low back pain selected from among the patients referred for abdominal computed tomography. RESULTS Sixteen (55%) of the 29 patients with low back pain had atherosclerotic calcifications visible on computed tomographic scans, whereas 11 (21%) of the 52 age-matched patients without low back pain were found to have aortic calcifications. Eleven (48%) patients with low back pain who were 50 years of age or less (n = 23) had aortic calcifications, whereas only 3 (8%) of the 36 control patients aged less than 50 years had aortic calcifications. There was no correlation between the amount of calcifications and the degree of disc degeneration assessed by computed tomographic discography. CONCLUSIONS A significant association is indicated between atheromatous lesions in the abdominal aorta and low back pain.

Magnetic resonance imaging findings in relation to the COL9A2 tryptophan allele among patients with sciatica.

Study Design. A follow-up of disc herniation (herniated nucleus pulposus [HNP]) resorption on magnetic resonance imaging (MRI). Objective. To assess the determinants of resorption of HNP. Summary of Background Data. Neovascularization in the outermost areas of HNP, presenting as an enhancing rim in gadolinium diethylenetriamine pentaacetic acid MR images, is thought to be a major determinant of spontaneous resorption of HNP. Methods. Patients with HNP-induced sciatica at baseline were rescanned at 2 months (N = 74) and after 12 months (N = 53). The volume of HNP (mm3), thickness (mm) and extent (%) of enhancement, and the degree of HNP migration (Komori classification) were analyzed. Repeated measures analysis of covariance was used in statistical analysis. Results. Significant resorption of HNP occurred from baseline to 2 months, although the resorption rate was more pronounced over the whole 1-year follow-up. Higher baseline scores of rim enhancement thickness, higher degree of HNP displacement in the Komori classification, and age category 41–50 years were associated with a higher resorption rate. Thickness of rim enhancement was a stronger determinant of spontaneous resorption than extent of rim enhancement. Clinical symptom alleviation occurs concordantly with a faster resorption rate. Conclusions. MRI is a useful prognostic tool for identifying patients with HNP-induced sciatica with a benign natural course.

Bony vibration stimulation test combined with magnetic resonance imaging. Can discography be replaced

Study Design. A cross-sectional study in sciatic population. Objectives. To evaluate the separate roles of nerve root entrapment—based on magnetic resonance imaging—and other discogenic pain mechanisms on disability and physical signs among symptomatic sciatic patients. Summary of Background Data. Data symptoms of sciatica are generally understood to be generated by nerve root compression, but other pain mechanisms of sciatica have been suggested. Methods. The authors obtained magnetic resonance scans from 160 patients with unilateral sciatic pain. The patients reported the intensity of their back and leg pain and their back-specific disability. Clinical examination and magnetic resonance imaging (1.5 T) was performed on every patient. The degree of disc displacement, neural enhancement, and nerve root compression was evaluated from magnetic resonance scans. The correlations of symptoms and signs with magnetic resonance imaging findings were calculated. Results. The degree of disc displacement in magnetic resonance imaging did not correlate with any subjective symptoms, nor did nerve root enhancement or nerve compression. Magnetic resonance imaging classification was associated, however, with straight leg raising restriction. In regression analysis, straight leg raising restriction was best explained with a simple classification of nonherniations versus herniations. Conclusions. The results suggest that a discogenic pain mechanism other than the nerve root entrapment generates the subjective symptoms among sciatic patients. The findings of this study thus indicate that magnetic resonance imaging is unable to distinguish sciatic patients in terms of the severity of their symptoms.

In vivo quantification of delayed gadolinium enhancement in the nucleus pulposus of human intervertebral disc

Study Design. The phenotype of patients with sciatica who have the Trp2 allele is characterized cross-sectionally. Objective. To determine whether it is possible to differentiate patients with the Trp2 allele clinically or by magnetic resonance imaging. Summary of Background Data. Several studies have indicated a positive family history for intervertebral disc disease. Previously, a dominantly inherited defect was identified in the COL9A2 gene that changed a codon for glutamine to that for tryptophan in the &agr;2 chain of collagen IX (Trp2 allele). This change may render intervertebral discs more fragile. Methods. Clinical findings, clinical symptoms, and magnetic resonance imaging (1.5-T) findings from 159 patients with sciatica were evaluated according to the presence of the Trp2 allele. Additionally, the magnetic resonance imaging scans of 22 family members from three families were evaluated. These scans were analyzed intervertebral disc and endplate degeneration, Schmorl’s nodes, transverse tears (hyperintensity in the region of Sharpey’s fibers), high-intensity zone lesions (bright spots in the dorsal anulus), and radial tears (hyperintense linear area from the nucleus to the outer part of the anulus on T2 sequences). Results. Six patients with sciatica and 11 family members had the Trp2 allele. No homozygotes were found. Clinical symptoms of patients with and those without the Trp2 allele were similar. Patients with sciatica who had the Trp2 allele were significantly more flexible (P < 0.05), according to the modified Schober measure. The disc and endplate degeneration in 6 patients with the Trp2 allele and their 18 controls (matched for age, occupation, gender) without the allele did not differ significantly, whereas family members with the Trp2 allele had a greater degree of disc and endplate degeneration at L5–S1. The overall prevalence of endplate degeneration was high in this study. The prevalences of dorsal transverse tears, high-intensity zone lesions, and Schmorl’s nodes did not differ among patients with sciatica or family members according to the presence of the Trp2 allele. There was, however, a trend for increased prevalence of radial tears in nonherniated discs among the Trp2 allele–positive subjects (3 of 6 patients with sciatica and 3 of 11 family members), as compared with the Trp2-negatives subjects (none of 18 “matched” patients or 11 family members). Conclusion. The patients with the Trp2 allele were more flexible, and more often tended to have a radial tear in a nonherniated disc than their control counterparts.

Gadolinium diethylenetriaminepentaacetic acid enhancement in magnetic resonance imaging in relation to symptoms and signs among sciatic patients: a cross-sectional study.

Study Design. The results of two noninvasive methods, magnetic resonance imaging and a bony vibration test, were compared with discographic pain provocation findings. Objectives. To evaluate whether the combination of magnetic resonance imaging and vibration pain provocation tests could be used to replace discography in low back pain diagnostics. Summary of Background Data. Magnetic resonance imaging gives a wealth of visual information on anatomic changes of the spine with often unknown clinical significance. Discographic examination of the spine is still the only widely accepted diagnostic method that can relate the pathoanatomic changes to the patients clinical pain. Internal anular rupture has been shown to be one of the sources of back pain. The bony vibration test of the spinal processes has been shown correlate well with discographic pain provocation tests in cases of internal anular rupture. Methods. The three lowest lumbar discs of 33 patients with back pain were examined by means of magnetic resonance imaging and a bony vibration stimulation test, and the results were compared with those from computed tomography-discography. Results. In cases of intradiscal magnetic resonance imaging findings, the vibration provocation test showed a sensitivity of 0.88 and a specificity of 0.50 compared with the discographic pain provocation test. If the patients with previous back surgery were excluded, the specificity was 0.75. In the cases of total anular rupture, the sensitivity was 0.50, and the specificity was 0.33. Conclusion. The combination of the two noninvasive methods, vibration stimulation and magnetic resonance imaging, gives more information on the origin of the back pain than magnetic resonance imaging alone. The pathoanatomic changes seen in magnetic resonance imaging can be correlated with the patients disorder more reliably using the vibration provocation test in the cases of partial anular ruptures. The use of discography can be limited mostly to cases with total anular ruptures detected by magnetic resonance imaging.