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Clincal Review of Lumbar Disc Herniation/ Sciatica
Clincal Review of Lumbar Disc Herniation/ Sciatica
By Dr. Sireen Gopal - Medical Literature review

Medical Spine Update and Literature Review of the Management of Lumbar Disc Herniation/ Clinical Sciatica!!

** The minority of patients with back or neck pain, who do not recover by 3 months account for up to 90% of total expenses related to this health problem,1-7 which exceed $60 billion per year in the United States

** Multiple studies have demonstrated little correlation to exist between strict radiographic signs of disc degeneration, disc herniation and clinical symptoms8-14

** Advances in diagnostic imaging has lead to Over-estimation of disease prevalence; Over-treatment of the disease with passive care (passive physical therapy, chiropractic etc); Validation of pain behavior and disability

** Prolonged bed rest has been shown to be one of the most costly errors in musculoskeletal care15. 2 days of bed rest has shown to be as effective as 2 wks 16

** Spontaneous disc resorption has been reported after disc herniations17-22, especially with large disc herniations19. The notion that surgery is necessary in a patient with a large disc extrusion is not supported in the literature, except in the one with serious neurological insult. Failure of passive non-operative treatment is not sufficient for the decision to operate 18

** Multiple studies have shown success rate up to 80-90% in treating lumbar herniated nucleus pulposus/clinical sciatica with radiological evidence of nerve root entrapment by aggressive conservative management 17-23

** Recent studies 24-26 have indicated that pain factors such as substance P, calcitonin gene-related peptide and inflammatory factors such as phospholipase A2 26 are present in significant abnormal amounts after disc herniation, causing a chemical radiculitis 27- clinically manifested as radiating limb pain

** Fluoroscopically28-35 guided transforaminal epidural steroid injections (ESI) 28-41 allow for precise, safe and effective delivery of high concentrations of injectate directly at the ventral aspect of the nerve root sleeve and posterior annulus. This allows effective pain control, facilitates active physical rehabilitation and time for spontaneous disc resorption

** Acute and subacute back and radiating limb pain should be controlled aggressively in the first three months to help retard chronic pain syndromes and prevent the 4D Syndrome of - Drug dependence, Disuse, Depression & Disability

** If pain is not controlled with specific source of pain treatments, surgery should be offered. This is often the case in spine conditions with coexisting spinal stenosis, spondylolisthesis etc. These patients with clear structural abnormalities should be discouraged from allowing chronic persistent symptoms to linger.

Some References:

1. Webster BS, Snook SH: The cost of 1989 worker, compensation low back pain claims. Spine 19: 1111, 1994.
2. Snook SH: Low back pain in industry. In White AA, Gordon SL (eds): Symposium on Idiopathic Low Back Pain. St Louis, CV Mosby, 1982.
3. Spengler DM, Bigos SJ, Martin NA, it al: Back injuries in industry: A retrospective study. I. Overview and cost analysis. Spine 11: 241, 1986.
4. Frymoyer JW, Pope MH, Clements JH, it al: Risk factors in low-back pain: An epidemiological study. J Bone Joint Surg (Am) 65: 213, 1983.
5. Andersson GBJ, Pope MH, Frymoyer JW: Epidemiology. In Pope MH, Frymoyer JW, Andersson G (eds); Occupational Low Back Pain. New York, Praeger, 1984, pp 101-114
6. Morris A: Identifying workers at risk to back injury is not guesswork. Occup Health Saf 55:16, 1985
7. Frymoyer W: Epidemilogy. In Frymoyer JW, Gordon SL (eds): Symposium on New Perspertives in Low Back Pain. Park Ridge, American Academy of Orthopaedic Surgeons, 1989, pp 19-33.
8. Frymoyer JW, Newberg A, Pope MH, et al: Spine radiographs in patients with low-back pain: An epidemiological study in men. J Bone Joint Surg (AM) 66: 1048, 1984
9. Fullenlove TM, Williams AJ; Comparative roentgen findings in symptomatic and asymptomatic backs. JAMA 168: 572, 1957
10. LaRocca H, Macnab IA: Value of pre-employment radiographic assessment of the lumbar spine. Can Med Assoc J 101: 383, 1969
11. Magora A, Schwartz A: Relation between the low back pain syndrome and x-ray findings. Scand J Rehabil Med 8: 115, 1976
12. Splithoff CA: Lumbosacral junction: Roentographic comparison of patients with and without back ache. JAMA 152: 1610, 1953
13. Torgeson WR, Dotler WE: Comaprative roetgenographic study of the asymptomatic and symptomatic lumbar spine. J Bone Joint Surg (Am) 58: 850, 1976
14. Dabbs VM, Dabbs LG: Correlation between disk height narrowing and low-back pain. Spine 15: 1366, 1990
15. Spitzer WO Le Blanc FE, Dupuis M, it at: Scientific approach to the assessment and management of activity-related spinal disorders: A monograph for clinicians. Report of the Quebec Task Force on Spinal Disorders. Spine 12(Suppl 7): S1, 1987.
16. Deyo RA, Diehl AK, Rosenthal M: How many days of bed rest for acute low back pain?. N Engl J Med 315: 1064, 1986
17. Bush K, Cowan N, Katz DE, et al: The natural history of sciatica associated with disc pathology: A prospective study with clinical and independent radiologic follow-up, Spine 17: 1205, 1992.
18. Teplick JG, Haskin ME. Spontaneus regression of hernated nucleus pulposus. AJR Am J Roentgenol 1985; 145: 371-5.
19. Saal JA, Saal JS, Herzog RJ. The natural history of lumbar intervertebral disc extrusions treated non-operatively. Spine 1990; 15; 683-6.
20. Delauch-Cavallier MC, Budget C, Laredo JD, et al. Disc herniation: Computed tomography scan changes after conservative treatment of nerve root compression. Spine 1992: 17; 927-33
21. Maigne JY, Rime B, Deligne B. Computed tomographic follow-up study of forty-eight cases of nonoperatively treated lumbar intervetebral disc herniation. Spine 1992, 17: 1071-4
22. Kimori H, Shinomiva K, Nakar O, et al. The natural history of herniated nucleus pulposus with radiculopathy. Spine 1996; 21(2); 225-9

23. Saal JA, Saal JS: Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy. Spine 14: 431, 1989
24. Weinstein J, Claverie W, Gibson. The pain of discography. Spine 1988; 13: 1344-8
25. Chatani K, Kawakami M, Weinstein JN, Meller ST, Gebhart GF. Characterization of thermal hyperalgesia, c-fos expression, and alterations in neuropeptides after mechanical irritation of the dorsal root ganglion. Spine 1995; 20: 277-89.
26. Saal JS, Franson RC, Dobrow R, Saal JA et al: High levels of inflammatory phospholipase A2 activity in lumbar spinal disc herniations. Spine 1990; 15:674-8
27. Marshall LL, Trethewie ER, Curtain CC. Chemical radiculitis. A clinical, physiological and immunological study. Clin Orthop 1977; 190: 61-7.
28. Renfrew DL, Moore TE, Kathol MH et al. Correct placement of epidural steroid injection: fluoroscopic guidance and contrast administration. Am J neuroradiol 1991; 12: 1003-7
29. El-Khouri GY, Ehara S, Weinstein JN et al. Epidural Steroid injection: a procedure ideally performed with fluorosopic control. Radiology 1988; 168:554-7
30. Lutz GE, Vad VB, Wisneske RJ. Fluoroscopic transforaminal Lumbar Epidural Steroids: An Outcome Study. Arch Phys Med Rehabil, Nov 1998; 79; 1362-66
31. Derby R, Bogduk N, Kine G. Precision percutaneous blocking procedures for localizing spine pain. Part 2. The lumbar neurazial compartment. Pain Digest 1993;3:175-88
32. Derby R, Kine G, Saal JA et al. Response to steroid and duration of radicular pain as predictors of surgical outcome. Spine 1992; 17: S176-83.
33. Weinstein SM, Herring SA, Derby R. Contemporary concepts in spine care: epidural steroid injections. Spine 1995; 20: 1842-6.
34. Bogduk N. Spine update. Epidural steroids. Spine 1995; 20:845-8
35. Bogduk N, Aprill C, Derby R. Epidural steroid injections. In: White AH, Schofferman J, editors. Spinal care diagnosis and treatment. St Louis (MO): Mosby; 1995. P 322-43
36. Stewart HD, Quinnell RC, Dann N. Epidurography in the management of sciatica. Br J Rheumatorl 1987; 26: 424-29
37. Klenerman L, Greenwood R et al. Lumbar epidural injections in the treatment of sciatica. Fr J Rheumatol 1984; 23: 35-8.
38. Snoek W, Weber H et al. Double blind evaluation of extradural methyl prednisolone for herniated lumbar disc. Acta Orthop Scand 1977; 48: 635-41.
39. Cuckler JM, Berini PA, Wiesel Sw, Et al. The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized. Double-blind study. J Bone Joint Surg Am 1985; 67:63-6
40. Ridley Mg, Kingsley GH et al. Outpatient lumbar epidural corticosteroid injection in the management of sciatica. Fr J Rheumatol 1988; 27: 295-99.
41. Dilke TF, Burry HC, Grahame R. Extradural corticosteroid injection in management of lumbar nerve root compression. BMJ 1973; 2:635-7
42. Bogduk N, Brazenor G, et al. Epidural steroids in the management of low back pain and sciatica of spinal origin. Report of the working party. Sydney: National Health and Medical Research Council; 1993. P 102-6