Acute Sciatica Research Articles

An Ayurveda Approach Towards Acute Sciatica with Paraesthesia

Sciatica is pain or paraesthesia which is radiates path of the sciatic nerve and its branches from the lower back through the hips and buttocks and down to the leg. A 41-year-old female patient with an acute low back ache to radiate to left lower limb with paraesthesia for three months came to Kayachikitsa IPD of Vaidyaratnam Ayurveda College on 18/3/24. The pain was graded eight out of ten in the VAS pain scale and her overall Oswestry low back pain score is 32 which means severe functional disability. She underwent for Vatakapha hara chikitsa protocol. It includes Rookshana, Snigda sweda, Vata hara, and Brihmana chikitsa. Ayurvedic preparations like Aadarisahacharadi kasayam, Suntibaladi choornam Vyoshadi guggulu were given Swedam, Patrapoliswedam, and Pizhichil, Shastika pinda swedam, Yoga vasti along with passive exercise were given. After 30 days of treatment outcome of these treatments found to be very positive. There was a substantial recovery in walking duration, heaviness, touch temperature perception and pain relief was observed. Subjective parameters like, SLR test, Oswestry low back pain disability questionnaire, Sciatica bothersome index, Sciatica frequency index, Roland morris low back pain and disability questionnaire was taken for assessment parameters. The patient got relief in all parameters after treatment. It was proved significant improvement of patient’s primary symptoms. These therapies reduce pain, stiffness and improve circulation.

Comparison of diclofenac with tramadol, tizanidine or placebo in the treatment of acute low back pain and sciatica: multi-center randomized controlled trial.

Low back pain (LBP) is a leading cause of disability worldwide and has posed numerous health and socioeconomic challenges. This study compared whether nonsteroidal anti-inflammatory drugs (NSAIDs) in combination with tramadol, tizanidine or placebo would be the best treatment regime to improve the Roland Morris Disability Questionnaire (RMDQ) scores at 1 week. This was a multi-center, double-blind, randomized, and placebo-controlled trial including adult patients with acute LBP and sciatica in three emergency departments in Hong Kong. Patients were randomized to the receive tramadol 50mg, tizanidine 2mg, or placebo every 6hours for 2weeks in a 1:1:1 ratio. The RMDQ and other secondary outcomes were measured at baseline, Day 2, 7, 14, 21, and 28. Data were analyzed on an intention to treat basis. Crude and adjusted mean differences in the changes of RMDQ and NRS scores from baseline to Day 7 between tizanidine/tramadol and placebo were determined with 95% confidence intervals. Two hundred and ninety-one patients were analyzed with the mean age of 47.4years and 57.7% were male. The primary outcome of mean difference in RMDQs on Day 7 (compared with baseline) was non-significant for tizanidine compared with placebo (adjusted mean difference - 0.56, 95% CI -2.48 to 1.37) and tramadol compared with placebo (adjusted mean difference - 0.85, 95% CI -2.80 to 1.10). Only 23.7% were fully compliant to the treatment allocated. Complier Average Causal Effect analysis also showed no difference in the primary outcome for the tizanidine and tramadol versus placebo. Among patients with acute LBP and sciatica presenting to the ED, adding tramadol or tizanidine to diclofenac did not improve functional recovery.

Cost-effectiveness of Transforaminal epidural steroid injections for patients with ACUTE sciatica: a randomized controlled trial

BackgroundTransforaminal epidural injections with steroids (TESI) are increasingly being used in patients sciatica. The STAR (steroids against radiculopathy)-trial aimed to evaluate the (cost-) effectiveness of TESI in patients with acute sciatica (< 8 weeks). This article contains the economic evaluation of the STAR-trial.MethodsParticipants were randomized to one of three study arms: Usual Care (UC), that is oral pain medication with or without physiotherapy, n = 45); intervention group 1: UC and transforaminal epidural steroid injection (TESI) 1 ml of 0.5% Levobupivacaine and 1 ml of 40 mg/ml Methylprednisolone and intervention group 2: UC and transforaminal epidural injection (TEI) with 1 ml of 0,5% Levobupivacaine and 1 ml of 0.9% NaCl (n = 50). The primary effect measure was health-related quality of life. Secondary outcomes were pain, functioning, and recovery. Costs were measured from a societal perspective, meaning that all costs were included, irrespective of who paid or benefited. Missing data were imputed using multiple imputation, and bootstrapping was used to estimate statistical uncertainty.ResultsNone of the between-group differences in effects were statistically significant for any of the outcomes (QALY, back pain, leg pain, functioning, and global perceived effect) at the 26-weeks follow-up. The adjusted mean difference in total societal costs was €1718 (95% confidence interval [CI]: − 3020 to 6052) for comparison 1 (intervention group 1 versus usual care), €1640 (95%CI: − 3354 to 6106) for comparison 2 (intervention group 1 versus intervention group 2), and €770 (95%CI: − 3758 to 5702) for comparison 3 (intervention group 2 versus usual care). Except for the intervention costs, none of the aggregate and disaggregate cost differences were statistically significant. The maximum probability of all interventions being cost-effective compared to the control was low (< 0.7) for all effect measures.ConclusionThese results suggest that adding TESI (or TEI) to usual care is not cost-effective compared to usual care in patients with acute sciatica (< 8 weeks) from a societal perspective in a Dutch healthcare setting.Trial registrationDutch National trial register: NTR4457 (March, 6th, 2014).

Knowledge of Back Pain and Spinal Disorders Among the General Population in the Western Region of Saudi Arabia.

Introduction Low back pain (LBP) is one of the most common global health problems and the second most common reason for seeking medical advice. However, most LBP does not indicate a serious disorder. Over half of the Saudi Arabian population experiences LBP at least once in their lives. Therefore, it is important to assess and understand how people manage this health problem. This study assessed back pain and spinal disorder knowledge among the general population in Saudi Arabia's western region. Methods This was a cross-sectional study of the general population in western Saudi Arabia. The data were collected using an online, self-administered, Arabic version of the validated questionnaire about LBP. A statistical analysis of the collected data was performed using a software program. Results A total of 754 eligible participants completed the questionnaire. Less than half of the participants could correctly define acute and chronic LBP and sciatica. Only 19.2% of participants were aware that medical history and clinical examinations are used to diagnose LBP. Young participants, university graduates, and unmarried participants had good LBP knowledge. Conclusion This study showed that the general population of Saudi Arabia in the Western region needs more knowledge about the definitions of acute and chronic LBP. However, they had fair knowledge about the aggravating factors and triggers of LBP. Young participants had better knowledge about LBP. Awareness campaigns with brochures and flyers can be used to increase the population's knowledge.

Author's Reply to the Letter of Van Boxem, Van Gaag, Van Zundert, and Kallewaard, Entitled 'Response to Ter Meulen et al. Effect of Transforaminal Epidural Corticosteroid Injections in Acute Sciatica'.

Author's Reply to the Letter of Van Boxem, Van Gaag, Van Zundert, and Kallewaard, Entitled 'Response to Ter Meulen et al. Effect of Transforaminal Epidural Corticosteroid Injections in Acute Sciatica'.

Effect of Transforaminal Epidural Corticosteroid Injections in Acute Sciatica A Randomized Controlled Trial.

Transforaminal epidural steroid injections (TESIs) are widely administered for sciatica. The aim of this trial was to evaluate the effectiveness of TESIs in patients with acute sciatica (<8wk). This study was conducted in two Dutch hospitals. Participants (n=141) were randomly assigned to: 1) usual care and TESI of 1ml of 40mg/ml Methylprednisolone plus 1ml of 0.5% Levobupivacaine (intervention 1); 2) usual care and transforaminal epidural injection with 1ml of 0.5% Levobupivacaine and 1ml NaCl 0.9% (intervention 2); 3) usual care consisting of oral pain medication with or without physiotherapy (control). Co-primary outcomes were back- and leg pain intensity, physical functioning and recovery measured during 6-month follow-up. There were no significant mean differences in co-primary outcomes between groups during follow-up, except for leg pain when comparing intervention group 1 with control (-0.96 95%CI:-1.83 to -0.09). For secondary outcomes, some significant between group differences were found for treatment satisfaction and surgery, but only when comparing intervention group 2 to control. Post-hoc analyses showed a significant difference in response (50% improvement of leg pain [yes/no]) between intervention 1 and the control group at 3 months and that both intervention groups used less opioids. Except for a statistically significanteffect of TESI on leg pain for patients with acute sciatica compared to usual care, there were no differences in co-primary outcomes. Nonetheless, transforaminal epidural injections seem to be associated with less opioid use, which warrants further exploration.

Sciatica in primary care – a case discussion

It is thought that more than half of adults will experience back pain in their life, and practice nurses will often be the first practitioners consulted. Cheryl Johnson and Gerri Mortimore explain what nurses need to know when they encounter this common complaint. Back pain is a common problem encountered in practice. It is estimated that 60% of the adult population experience low back pain throughout their lifetime ( Campbell and Colvin, 2013 ) that over 80% of the population will report low back pain throughout their lifetime (Walker, 2000) with between 13–40% developing sciatica ( NICE, 2022 ). This article will discuss a case study who presented to a community trainee enhanced clinical practitioner (tECP) with symptoms of lumbar radiculopathy. and After clinical examination and further tests a diagnosis of acute sciatica was given. This article will explore how the history taking, clinical examination and special tests led to this diagnosis. Moreover, it will examine the underlying evidence underpinning the examination and tests undertaken.

Treatment of True and False Acute Sciatica

Treatment of True and False Acute Sciatica

Spinal subdural hematoma in a patient with immune thrombocytopenic purpura following microvascular decompression: a rare case report.

This article reports a case of spontaneous spinal subdural hematoma (SSDH) after brain surgery in a patient with immune thrombocytopenic purpura (ITP), reviews the relevant literature, and discusses the etiology, pathogenesis, and clinical features of SSDH in patients with ITP. A male patient in his early 50 s with an 8-year history of ITP and suffering from coexistent hemifacial spasm and trigeminal neuralgia underwent microvascular decompression in our department. His preoperative corrected platelet count was within the normal range. On postoperative day 2, the patient complained of acute low back pain and sciatica. Lumbar magnetic resonance imaging demonstrated an SSDH extending from L3 to L4 with a significantly decreased platelet count (30.0 × 109/L). The pain was gradually relieved after 2 weeks of conservative treatment, and no neurological deficit occurred during the 1-year follow-up. Brain surgery may increase the risk of postoperative SSDH in patients with ITP. Clinicians planning brain surgery must conduct a rigorous assessment through detailed physical examination, laboratory tests, and medical history records and maintain perioperative platelet counts within the normal range to prevent various risks associated with spinal cord compression.

Formulation and evaluation of Ketorolac tromethamine for transdermal drug delivery system

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as Ketorolac Tromethamine are widely recommended to treat pain caused by osteoarthritis, ankylosing spondylitis, acute sciatica, rheumatoid arthritis and low back pain. Modern drug delivery technology, such as transdermal patches, is mostly used in the treatment of numerous diseases. As first-pass metabolism is avoided. Transdermal drug delivery systems (TDDS) can efficiently enhance bioavailability and help with the planned and controlled release of drug molecules into the systemic circulation. The purpose of this work was to produce matrix-type Ketorolac tromethamine transdermal patches by solvent evaporation using different polymer ratios, such as HPMC 15 cps, HPMC E5, and Eudragit S 100. Along with solvents like methanol and chloroform, plasticizers like glycerine, propylene glycol, and PEG 200 are used in this formulation. According to the FTIR study, Ketorolac Tromethamine had no significant interactions with other excipients. The following evaluations are carried out such as thickness, weight variation, folding durability, moisture content, drug content, surface pH, and In vitro diffusion are all evaluated for the prepared patches.

The Benefit of Early Epidural Corticosteroid Injections for Acute Sciatica-Associated Lower Back Pain: A Four-Year Case Series in Lebanon.

Background Early epidural steroid injections are currently widely used for patients experiencing lumbago. However, there is uncertainty about their efficacy, such as the limitation of continuous drug infusion and the need for well-trained physicians on this technique. The main objective of this study was to evaluate the effectiveness of early epidural steroid injections in treating patients with acute sciatica in the lower back in terms of symptom relief and recurrence rate. Methods A case series was conducted in Lebanon from 2015 to 2019. We recruited 98patients suffering from sciatica due to disc disease over three-time intervals: two weeks, one, and three months. The immediate results accounted for the intensity of various symptoms (numerical rating scale (NRS) for pain) and the assessment of patient satisfaction (Macnab criteria). Results The clinical results showed at least a three-pointpain relief according to Numerical Rating Scale (NRS) and a good grade according to MacNab (P <0.001), with only 10.4% of the total population having a positive leg raise test post-injection. The maximum benefit was noted after two weeks from the injection with a 5.7 mean change in NRS (p<0.001) with a good/excellent response in MacNaband a 4.9 change with only a good response after one month. This study noticed a rebound phenomenon where around half of the patients needed two steroid injections after three months (39.6 % after three monthsand 17.9 % after six months). Conclusion Even though current guidelines worldwide may suggest the use of conservative treatmentfor low back pain with acute sciatica, our study has demonstrated the effectiveness of epidural steroid injections in the Lebanese population with a significant outcome.

Conservative management for spontaneous lumbar facet joint hemarthrosis in severe hemophilia a: A rare case report

Spontaneous lumbar facet joint bleeding is rarely observed in patients with hemophilia. Since it is categorized as a spinal epidural hematoma, surgery is the main treatment. Conservative treatment was successful in patients with minor or absent neurological deficits. We aimed to present the case of a patient with severe hemophilia who suffered from acute sciatica caused by lumbar facet joint hematoma. Nonsurgical treatment using a multidimensional approach was provided. The hemarthrosis is completely resolved. The patient recovered from clinical neurological symptoms without recurrence throughout the 4-year follow-up period. Spontaneous lumbar facet joint hemarthrosis in patients with severe hemophilia who present with mild neurological symptoms can be conservatively treated if the hemarthrosis is recognized early. Moreover, a multidisciplinary team approach is paramount in achieving good patient outcomes.

Comparing the therapeutic effects of two Iranian musical modes with standard treatment in acute sciatica pain: a pilot study

Comparing the therapeutic effects of two Iranian musical modes with standard treatment in acute sciatica pain: a pilot study

Formulation In Vitro and In Vivo Evaluation of Ketorolac Topical Hydrogel

Non-steroidal anti-inflammatory drugs (NSAIDs) like Ketorolac Tromethamine are frequently prescribed to alleviate pain associated with osteoarthritis, ankylosing spondylitis, acute sciatica, rheumatoid arthritis, and low back pain. Hydrogels are polymeric three-dimensional networks that are able to consume significant volumes of water and remain insoluble in water due to their physical and chemical crosslinking. They respond to temperature, pH and ionic strength. They can be prepared by using natural polymers such as dextran, pectin, alginate, or synthetic polymers such as polyvinyl alcohol, polyethylene oxide, and poly–hydroxy ethyl methacrylate. Hydrogels are used to deliver several drugs. Today, hydrogels have found a wide range of applications due to their non-toxic nature and low cost. The purpose of the current research was to formulate and assess a topical gel based on hydrogel that contained Ketorolac Tromethamine to treat inflammation and pain while reducing the gastrointestinal side effects associated with oral treatment. According to the FTIR analysis, Ketorolac Tromethamine doesn't interact with other excipients in a significant way. The physical characteristics, pH level, extrudability, spreadability, swelling property, in-vitro drug release study of hydrogel formulations were assessed. Using a dialysis membrane and a phosphate buffer solution with a pH of 7.4, in vitro and ex vivo release studies were conducted on the Franz diffusion cell. Among all formulations, HF4 showed high spreadability of 25.2 ±0.3 gm./cm/sec, extrudability, swelling index, in vitro drug release, and ex vivo drug diffusion. HF4 hydrogel showed no signs of skin irritation. The final formulation HF4 hydrogel shows an equal analgesic and anti-inflammatory effect as standard Ketorolac gel. It was found from the drug release kinetics that the Topical Ketorolac hydrogel HF4 drug release mechanism follows the Higuchi model and zero order.

Discectomy Compared with Standardized Nonoperative Care for Chronic Sciatica Due to a Lumbar Disc Herniation: A Secondary Analysis of a Randomized Controlled Trial with 2-Year Follow-up.

Randomized controlled trials evaluating acute sciatica have not demonstrated prolonged improvements in terms of patient-reported pain and function. For chronic sciatica, however, microdiscectomy has been found to be superior at 1 year. Whether this effect persists during the second year is not known. The purpose of the present study was to report the 2-year outcomes following lumbar microdiscectomy as compared with standardized nonoperative care for the treatment of chronic sciatica resulting from a lumbar disc herniation. The present study is a secondary analysis of a previously reported randomized controlled trial with extension to 2 years of follow-up. Patients with radiculopathy for 4 to 12 months resulting from an L4-L5 or L5-S1 disc herniation were randomized to microdiscectomy or 6 months of nonoperative care followed by surgery if needed. Intention-to-treat analysis was performed at 2 years for the primary outcome (the intensity of leg pain) (range of possible scores, 0 [no pain] to 10 [worst pain]) as well as for secondary outcomes (including the Oswestry Disability Index score, the intensity of back pain, and quality of life). One hundred and twenty-eight patients were randomized in the present study. Twenty-four (38%) of the 64 patients who had been randomized to nonoperative care crossed over to surgical treatment by 2 years following enrollment. At the 2-year time point, the follow-up rate was approximately 70%. At 2 years, the operative group had less leg pain than the nonoperative group (mean, 2.8 ± 0.4 compared with 4.2 ± 0.4; treatment effect, 1.3 [95% confidence interval, 0.3 to 2.4]). The treatment effect favored surgery for all secondary outcome measures at 6 months and 1 year and for back pain intensity and physical function at 2 years. At 2 years, the present study showed that microdiscectomy was superior to nonoperative care for the treatment of chronic sciatica resulting from an L4-L5 or L5-S1 disc herniation. However, the difference between the groups did not surpass the minimal clinically important difference at 2 years as was reached at earlier follow-up points, likely as the result of patients crossing over from nonoperative to operative treatment. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

A systematic review and meta-analysis of the effectiveness and adverse events of gabapentin and pregabalin for sciatica pain

AimThis SR aims to assess the effectiveness of pregabalin and gabapentin on pain and disability caused by acute sciatica and the adverse events associated with their clinical use. DesignSystematic review. DatabasesElectronic databases of Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Clinical Trials.gov were searched from their inception until March 1st of 2021. Selection criteriaRandomized trials (RCT) with adults>18 years old with acute sciatica for a minimum of 1 week and a maximum of 1 year (at least moderate pain). Data treatmentThe outcomes were pain, disability and adverse events. Data was summarized using odds ratio and mean difference. GRADE was used to calculate the level of evidence. ResultsEight RCT involving 747 participants were included. The effect of pregabalin was assessed in 3 RCT and in one three-arm trial (pregabalin vs limaprost vs a combination of limaprost and pregabalin). Two trials assessed the effect of gabapentin compared with placebo and one compared with tramadol. One study assessed the effect of gabapentin vs pregabalin in a crossover head-to-head trial.A statistically significant improvement on leg pain at 2 weeks and leg pain with movement at 3 and 4 months was found in a RCT comparing gabapentin with placebo. There were no statistically differences on the remaining time periods assessed for leg pain, low back pain and functional disability. ConclusionsThis SR provides clear evidence for lack of effectiveness of pregabalin and gabapentin for sciatica pain management. In view of this, its routine clinical use cannot be supported.

FORMULATION AND EVALUATION OF SLN BASED TOPICAL GEL OF KETOROLAC TROMETHAMINE

Ketorolac tromethamine is frequently non-steroidal anti-inflammatory drug (NSAIDs) with analgesic, anti-inflammatory and antipyretic properties, is also nice in relieving symptoms of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, acute sciatica and low back pain. Solid lipid nanoparticles (SLNs) are able to be used for the focused on of anti-inflammatory drugs, thus accomplish most significant advantages such as reduction in total dose and prevention of systemic toxicity and unusual side effects. The objective of the present investigation was to prepare &amp; evaluate solid lipid nanoparticle (SLN) based topical gel of non-steroidal anti-inflammatory drug (NSAID) ketorolac tromethamine for the cure of arthritis which would attenuate the gastrointestinal related toxicities related with oral administration. SLNs had been prepared by means of low temperature solidification technique and characterize by means of particle measurement, analysis, FTIR spectroscopy, drug entrapment efficiency, SEM, in vitro In vitro release research were performed on Franz diffusion cell the usage of dialysis membrane in phosphate buffer solution of pH 7.4. The FTIR study indicates no predominant interaction of ketorolac tromethamine with different component ingredients and the Scanning Electron Microscope study revealed that the drug is molecularly dispersion into the lipid. The particle measurement determination confirms the particle distribution in the nanoparticle range (27% volume to 56% volume). In vitro drug release using the dialysis membrane as of the prepared SLNs is greatly higher than the pure drug. The stability of the formulation shows the stability of the formulation besides changing its performances on storage. Hence formulation of ketorolac tromethamine in SLN, enhances the dissolution price as properly as it will enhance the bioavailability of the drug which ought to the stabilized for the duration of storage.

STeroids Against Radiculopathy (STAR) trial: a statistical analysis plan

BackgroundTransforaminal epidural injections with steroids (TESI) are used increasingly for patients with sciatica. However, their safety, effectiveness, and cost-effectiveness are still a matter of debate. This a priori statistical analysis plan describes the methodology of the analysis for the STAR trial that assesses the (cost-)effectiveness of TESI during the acute stage of sciatica (< 8 weeks).MethodsThe STAR trial is a multicentre, randomized controlled, prospective trial (RCT) investigating the (cost-)effectiveness of TESI by making a three-group comparison among patients with acute sciatica due to a herniated lumbar disc (< 8 weeks): (1) TESI combined with levobupivacaine added to oral pain medication (intervention group 1) versus oral pain medication alone (control group), (2) intervention group 1 versus transforaminal epidural injection with levobupivacaine and saline solution added to oral pain medication (intervention group 2), and (3) intervention group 2 versus control group. Co-primary outcomes were physical functioning (Roland Morris Disability Questionnaire), pain intensity (10-point numerical rating scale), and global perceived recovery (7-point Likert scale, dichotomized into ‘recovered’ and ‘not recovered’). For all three comparisons, we defined the following minimal clinically relevant between-group differences: two points for pain intensity (range 0–10), four points for physical functioning (range 0–24) and a 20% difference in recovery rate. Secondary outcomes are health-related quality of life (EQ-5D-5L) and patient satisfaction (7-point Likert scale) and surgery rate. We also collected resource use data to perform an economic evaluation. Analyses will be conducted by intention-to-treat with p < 0.05 (two-tailed) for all three comparisons. Effects will be estimated using mixed models by maximum likelihood. For each comparison, mean differences, or difference in proportions, between groups will be tested per time point and an overall mean difference, or difference in proportions, between groups during the complete duration of follow-up (6 months) will be estimated. In the economic evaluation, Multivariate Imputation by Chained Equations will be used to handle missing data. Cost and effect differences will be estimated using seemingly unrelated regression, and uncertainty will be estimated using bootstrapping techniques.DiscussionThis statistical analysis plan provides detailed information on the intended analysis of the STAR trial, which aims to deliver evidence about the (cost-)effectiveness of TESI during the acute phase of sciatica (< 8 weeks).Trial registrationDutch National trial register NTR4457 (6 March 2014)

Physical Therapy Referral From Primary Care for Acute Back Pain With Sciatica : A Randomized Controlled Trial.

Few studies have examined primary care management for acute sciatica, including referral to physical therapy. To evaluate whether early referral to physical therapy reduced disability more than usual care (UC) alone for patients with acute sciatica. Randomized controlled clinical trial. (ClinicalTrials.gov: NCT02391350). 2 health care systems in Salt Lake City, Utah. 220 adults aged 18 to 60 years with sciatica of less than 90 days' duration who were making an initial primary care consultation. All participants received imaging and medication at the discretion of the primary care provider before enrollment. A total of 110 participants randomly assigned to UC were provided 1 session of education, and 110 participants randomly assigned to early physical therapy (EPT) were provided 1 education session and then referred for 4 weeks of physical therapy, including exercise and manual therapy. The primary outcome was the Oswestry Disability Index (OSW) score after 6 months. Secondary outcomes were pain intensity, patient-reported treatment success, health care use, and missed workdays. Participants in the EPT group had greater improvement from baseline to 6 months for the primary outcome (relative difference, -5.4 points [95% CI, -9.4 to -1.3 points]; P = 0.009). The OSW and several secondary outcomes favored EPT after 4 weeks. After 1 year, between-group differences favored EPT for the OSW (relative difference, -4.8 points [CI, -8.9 to -0.7 points]) and back pain intensity (relative difference, -1.0 points [CI, -1.6 to -0.4 points]). The EPT group was more likely to self-report treatment success after 1 year (45.2%) than the UC group (27.6%) (relative risk, 1.6 [CI, 1.1 to 2.4]). There were no significant differences in health care use or missed workdays. The patients and providers were unblinded, and specific physical therapy interventions responsible for effects could not be determined. Referral from primary care to physical therapy for recent-onset sciatica improved disability and other outcomes compared with UC. Agency for Healthcare Research and Quality.

69. Ischemic spinal nerve root injury secondary to herniated lumbar intervertebral disc

BACKGROUND CONTEXT The painful clinical sequelae associated with sciatica secondary to intervertebral disc herniation have been traditionally attributed to mechanical compression of the spinal nerve root. More recent studies have also implicated inflammatory mediators and microvascular changes in the pathogenesis of acute sciatica. The application of nucleus pulposus (NP) to a spinal nerve root has been shown to induce thrombus formation in the associated nerve microvasculature and result in greater injury to the axons in the center than in the periphery, suggesting an ischemic mechanism of injury. The spinal nerve blood flow changes that are associated with nerve dysfunction seen in acute sciatica offer a potential target for therapeutic intervention. The VEGF angiogenic cytokines have been demonstrated to be potent stimulators of the differentiation and function of vascular endothelial cells after injury. PURPOSE To determine the relationship between the severity of spinal nerve root injury in patients with acute sciatica secondary to lumbar disc herniation (AS/LDH) undergoing surgical discectomy and the levels of VEGF-A and VEGF-B in serum, spinal nerve root lavage and disc tissue homogenate. STUDY DESIGN/SETTING ELISA cytokine immunoassay. PATIENT SAMPLE Twenty-four patients with AS/LDH of less than 16 weeks duration, undergoing laminectomy discectomy surgery. OUTCOME MEASURES VEGF-A and VEGF-Bconcentrations (pg/ml) in herniated nucleus pulposus homogenate (HNP-H), spinal nerve root lavagate (SN-L) and serum. METHODS At the time of surgery, the spinal nerve root was lavaged with 5 cc of saline, the extruded disc tissue removed surgically and serum samples were obtained. Disc and lavagate samples were stored in physiological buffer with protease inhibitors at -80° C. The concentrations of VEGF-A and VEGF-Bin disc tissue homogenate, serum and lavagate samples were measured in triplicate using ELISA immunoassay. Research ethics committee approval was obtained. RESULTS In AS/LDH patients, VAS pain and significant spinal nerve root deficit scores (3.0 - 4.0/5) correlated closely with serum and HNP-H tissue levels of VEGF-A and VEGF-B (Pearson r=0.78). In 11/24 patients, elevated VEGF-A and B concentrations correlated to a moderate degree with TNFα and IL-2, 6 and 8 inflammatory cytokine levels (r=0.61). Low concentrations of VEGF and inflammatory cytokine concentrations were seen in all SN-L test samples. CONCLUSIONS In patients with acute sciatica secondary to lumbar disc herniation, the severity of spinal nerve injury appears to be related to a combined mechanism, involving ischemic and inflammatory components. This research study was funded by grants from the National Institutes of Health, Bethesda, USA and from the University of British Columbia Orthopaedic Research Excellence Fund. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.