Lumbar Ischialgia Research Articles

Features of clinical manifestations, diagnosis and treatment of Bertolotti syndrome: а clinical case

BACKGROUND: One of the causes of pain in the lumbar spine may be congenital spinal column malformations. Bertolotti syndrome is a clinical and radiological symptom complex associated with sacralization of the LV vertebra, leading to disruption of the biomechanics of the lumbosacral spine and accelerated degeneration of facet joints and intervertebral discs, followed by foraminal and central stenosis of the spinal canal. The clinical manifestations of the disease can be polymorphic, and their cause is multifactorial. Thus, along with pain in the lumbar spine, patients with sacralization of the LV vertebra suffer from numbness and paresthesia in the lower extremities. The incidence of pathology ranges from 4% to 8%, mainly affecting elderly and mature people. СLINICAL CASE DESCRIPTION: Patient S was born in 1982 with long-term nonspecific pain in the back and lower limb; she presented to the Neurosurgical Department of the Irkutsk Scientific Center for Surgery and Traumatology. During a clinical neurological examination and additional introscopic studies of the lumbar spine, dorsopathy diagnosed. Degenerative spondyloarthrosis LIV–LV grade III according to D. Weishaupt. Sacralization of the LV vertebra type IIa according to Castellvi A.E. Syndrome of lumbar ischialgia on the right. Persistent pain and muscle-tonic syndrome. Minimally invasive interventional treatment was performed: pulsed radiofrequency ablation of the dorsal ganglion and radicular nerve at the level of the foraminal openings LIV–LV on the right and thermal radiofrequency ablation of the recurrent nerve of Luschka at the level of LIV–LV and LV–SI on the right. In the postoperative period, the intensity of the pain syndrome decreased, and the patient was discharged to work. CONCLUSION: A promising method of minimally invasive surgery is radiofrequency ablation in the area of neoarthrosis for denervation and relief of pathological pain impulses. Assessing the patient’s complaints, carefully collecting anamnesis, interpreting data from a clinical and neurological examination, and introscopic methods of examining the lumbar spine enables establishing an accurate diagnosis and selecting the most effective treatment method.

Nonsteroidal anti-inflammatory drugs, muscle relaxants, and B-group vitamins in the treatment of lumbar ischialgia

Nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants are used orally or intramuscularly (IM) to treat lumbar ischialgia caused by musculoskeletal disorders or radiculopathy. A comparative study has been conducted to investigate the efficacy and safety of the NSAID meloxicam (Amelotex®) injected intramuscularly and into the trigger points in combination with tolperisone and B-group vitamins for lumbar ischialgia.Patients and methods. The investigation enrolled 62 patients aged 30–60 years with lumbar ischialgia, who were randomized into three equal groups. Group 1 patients were injected with meloxicam 1.5 ml (15 mg of its active ingredient) into the trigger points daily for 3 days, followed by one 15-mg tablet daily for 14 days; Group 2 received IM meloxicam 15 mg daily for 3 days, followed by one 15-mg tablet daily for 14 days; Group 3 had IM meloxicam 15 mg daily for 3 days, followed by one 15-mg tablet daily for 14 days in combination with tolperisone (Calmirex®) as tablets: 150 mg (Day 1 of therapy), 300 mg (Day 2), and 450 mg daily (Day 3 until the end of therapy). All the patients received IM Vitamin B complex (Compligam B®) 2 ml for 5 days. The treatment efficiency was evaluated using the pain visual analogue scale (VAS), the Oswestry disability questionnaire, and the McGill pain questionnaire, the range of motion, and the severity of neurodystrophic syndrome.Results and discussion. All the patient groups showed a rapid and substantial pain reduction on the VAS and a functional activity improvement according to the Oswestry scale, which made it possible to complete the treatment within an average of 9.6 days. Groups 3 and 1 exhibited a faster improvement and, as a result, a shorter therapy duration on 8.6±1.2 and 9.2±0.9 days than did Group 2 (8.6±1.2 days). On day 2 of treatment, there was a more considerable pain reduction on the VAS in Group 1 that received meloxicam injections into the trigger zones. The administration of meloxicam intramuscularly and into the trigger zones in combination with tolperisone and vitamin B complex was noted to be safe and well tolerated.Conclusion. The injection of Amelotex into the trigger zones is highly effective and safe in treating lumbar ischialgia. An NSAID (meloxicam) in combination with a muscle relaxant (tolperisone) speeds up recovery and shortens the duration of NSAID intake.

Bioactive concentrate from small sea fish: evaluation of the efficacy and safety of the drug on the basis of the analysis of 37 clinical trials

Injectable Alflutop® (the bioactive concentrate from small sea fish (BCSSF)) belongs to the pharmacological group of symptomatic slow-acting drugs for osteoarthritis. This drug has been widely used in our country for 25 years. During this time, 37 of its clinical trials (n=3676) have been conducted in Russia and post-Soviet countries, mainly in patients with knee osteoarthritis (OA) and nonspecific back pain. These are mainly open-label trials, a major portion of which has been performed at the good methodological level, by using active control and up-to-date methods to assess treatment results. Two works are double-blind placebo-controlled trials (DBPCTs) conducted in compliance with the modern requirements of evidence-based medicine – this is an evaluation of the efficacy of BCSSF in knee OA and vertebrogenic lumbar ischialgia. All the trials have shown a good therapeutic potential of BCSSF: on the average, after the cycle use of the agent, there is a 40–60% decrease in pain intensity as compared to the baseline level. A two-year DBPCT of the efficacy of BCSSF in knee OA has also confirmed that the concentrate has a structure-modifying effect. At the same time, all the trials have demonstrated that BCSSF is well tolerated and very rarely causes adverse reactions that require discontinuation of treatment.

Assessment of vertebral pathology of drivers of vehicles of industrial enterprises

One of the many professional groups employed in many sectors of the economy is truck drivers, whose work is characterized by a complex of adverse production factors, of which physical activity, vibration, adverse microclimate, intensity of work, as a rule, are the main reasons for the formation of diseases of the musculoskeletal system, including vertebrogenic pathology. According to the results of a polyclinic examination of male truck drivers employed at industrial enterprises of the Republic of Bashkortostan, 73.8 % have vertebral diseases of the cervical spine (cervicalgia/cervicobrachialgia) and 89.2 %. — of the lumbosacral one (lumbalgia/ lumbar ischialgia, radiculopathy). An increase in the length of service negatively affects the course of the disease, leading to an increase in the neurological deficit from the reflex stage in the group of people with a work experience of up to 9 years to the compression-radicular stage with an experience of more than 20 years. The data presented indicate the need to develop a set of targeted measures of sanitary-hygienic and medical-rehabilitation nature.

On the issue of evaluation of vertebrogenic pathology in professional drivers at the stage of outpatient visit

Truck drivers represent one of numerous occupational groups employed in many economic sectors. Their work is characterized by a complex of adverse occupational factors. The greatest risk for the development of musculoskeletal diseases, including vertebral pathology, is associated with vibration, adverse environment, and work stress. Analysis of the state of health in 65 male drivers from trucking industry is carried out on the basis of results of outpatient examination. It included medical history, assessment of the severity of pain according to a visual analog scale, and instrumental methods of diagnosis. Vertebrogenic diseases of the cervical spine (cervicalgia, cervicobrachialgia) were detected according to the results of examination in 73.8% of drivers and diseases of the lumbosacral region (low back pain, lumbar ischialgia, radiculopathy) in 89.2% of drivers. Increase in the length of service negatively affects the course of the disease, leading to an increase in neurologic impairment from the reflex stage in the group of people with work experience of up to 9 years to the stage of radicular compression in the group with work experience of more than 20 years. Presented data indicate the need to develop a set of targeted measures of sanitary and hygienic and therapeutic and preventive nature.

Treatment of patients with acute and subacute lumbodynia and lumbar ischialgia

No effect of outpatient treatment is observed in some patients with acute nonspecific lumbodynia and lumbar ischialgia; therefore they are referred to pain management departments or centers for specialized examination and treatment.Objective: to study of the anatomical causes of pain and the efficiency of celecoxib (Dilaxa) treatment in patients with acute and subacute lumbodynia and lumbar ischialgia in the inpatient setting.Patients and methods. Eighty patients (47 women and 33 men; mean age, 51.0±15.3 years) with acute and subacute lumbodynia (n=11) or lumbar ischialgia (n=69) were followed up. Pain intensity was assessed using a visual analogue scale (VAS); functional limitation was rated according to the Roland–Morris scale (RMS). To reduce the intensity of pain syndrome, patients took oral celecoxib (Dilaxa) 200 mg twice daily. Therapeutic blockades with anesthetics and glucocorticoids were used in some cases of damage to the sacroiliac joint (SIJ) or facet joints (FJ). Patients were informed of the benign nature of the disease; they did therapeutic exercises.Results and discussion. The causes of pain were ascertained to be injuries of SIJ (48,8%), FJ and SIJ (18,8%), FJ (17,5%), herniated disc (10%), piriformis syndrome (2.5%), and piriformis syndrome and SIJ injury (2.5%). The duration of treatment averaged 11.0±2.4 days. By the end of the study, there was a clinically significant reduction in pain in 86% of patients. The treatment resulted in a 2.4-fold average reduction in pain intensity (from 7.0 to 2.9 VAS scores): a 4-fold reduction in patients with lumbodynia (from 6.4 to 1.6 scores) and a 2.3-fold one in those with lumbar ischialgia (from 7.1 to 3.1. scores); the degree of disability reduced by an average of 1.9 times (from 8.1 to 4.3 RMS scores): by 3.6 times (from 6.8 to 1.9 scores) and 1.9 (from 8,3 to 4,7 scores) times in patients with lumbodynia and in those with lumbar ischialgia, respectively. No adverse events were observed during the treatment period.Conclusion. There were high SIJ and FJ injury rates in subacute lumbar ischialgia. Celecoxib was noted to be highly effective and safe in treating acute and subacute lumbar ischialgia and lumbodynia.

Back pain and osteoporosis

The aging process is accompanied by a structural change and a decrease in the functional activity of organs and tissues, including the bone, with the development of osteoporosis (OP).Objective: to assess the characteristics of pain syndrome in OP patients with nonspecific chronic vertebrogenic lumbar ischialgia (CLI).Patients and methods. Sixty elderly patients with CLI in the presence and absence of OP were examined. All the patients underwent dual-energy X-ray absorptiometry and ultrasound to diagnose the degree of OP and spinal deformity; a flexible rod was used according to the method described by M.A. Kathleen to estimate the angle of kyphosis, lordosis, and scoliosis. The investigators determined pain intensity by a numerical rating scale, the presence of a neuropathic pain component by the DN4 pain scale, the level of anxiety and depression by the Hospital Anxiety and Depression Scale, cognitive status by the Montreal Cognitive Function Rating Scale, the degree of disability by the Oswestry questionnaire, and quality of life by the SF-12 Health Survey.Results and discussion. Our study showed that OP alone is not a cause of CLI in elderly patients. There were no statistically significant differences in the sources and intensity of pain, the degree of anxiety and depressive disorders, impaired quality of life, cognitive status, and degree of disability in patients with chronic lumbar pain syndrome in the presence and absence of OP. Vertebral deformity resulting from OP leads mainly to an obvious poor posture with an increase in thoracic kyphosis, straightening of lumbar lordosis, and S-curve lumbar and thoracic scoliosis, which can also cause secondary muscle spasm.Patients with back pain in the presence of OP are treated in accordance with the general principles of management of patients with non-specific back pain, but taking into account the underlying disease. The paper presents current recommendations for the treatment of nonspecific back pain, for the management of patients with OP, as well as the updated clinical recommendations for the prevention of fractures in OP and osteopenia.Conclusion. Patients with OP are noted to have predominantly chronic musculoskeletal pain in the presence of severe spinal deformity, but the level of this evidence is very low. The features of pain syndrome in patients with nonspecific vertebrogenic chronic lumbar ischialgia in the presence of OP call for further investigations.

Factors influencing the efficacy of nonsteroidal anti-inflammatory drugs for acute low back pain. The results of the multicenter observational «CARAMBOL» (Clinical Analysis of Results of Analgesia by Meloxicam and its Safety in Acute Lumbodynia) study

Nonsteroidal anti-inflammatory drugs (NSAIDs) are a main tool to treat acute nonspecific low back pain (NLBP). However, no factors that influence the efficacy of these drugs have been identified to the present day.Objective: to evaluate the therapeutic effect of and tolerance to NSAIDs (meloxicam) in treating acute NLBS and to identify the factors influencing the efficacy of this drug.Patients and methods. A study group consisted of 2078 patients (mean age 46.3±13.4 years; women 56.6%) with acute NLBS who had been treated in real clinical practice. The level of pain was estimated using a 0–10 point numerical rating scale (NRS). Initially, the pain level averaged 6.69±1.65 scores; 57.0% of patients were noted to have severe pain (≥7 NRS scores). Pain at rest persisted in 32.0% of patients; that at night was in 19.0%; sensation of stiffness in 60.7%, irradiation to the leg in 28.2%, and lumbar ischialgia in 9.6%. 70.2% of patients had been previously treated with NSAIDs for NLBS, while only 28.0% rated their efficacy as good. All the patients were prescribed meloxicam at a dose of 15 mg/day for a period of up to 2 weeks. 86.1% of the patients received meloxicam intramuscular for 2 days, then orally; 13.9% took the drug only orally. 52.3% of the patients also used muscle relaxants; 17.4% received oral or intramuscular B vitamins. The study estimated the rate of complete pain relief when NSAIDs were used for up to 2 weeks.Results and discussion. Complete pain relief was achieved in 75.2% of patients. 83.7% of patients rated the effect of treatment as good or excellent. Undesired drug reactions were recorded in 4.6% of patients. Female gender had no effect on treatment outcome (odds ratio (OR)=0.967; 95% confidence interval (CI), 0.795–1.177; p=0.763). Age over 65 years, the first NLBS episode, and a good NSAID effect in a history were associated with the best treatment result: OR=2.053 (95% CI, 1.5920–2.642), p<0.001; 1.415 (1.09–1.836), p=0.009; and 1.937 (1.513–2.481), p<0.001, respectively. Severe pain (≥7 NRS scores), persistent pain at rest and at night, and especially lumbar ischialgia indicated the worst result: OR=0.481 (95% CI, 0.393–0.588), p<0.001; 0.559 (0.441–0.709), p<0.001; 0.511 (0.413–0.631), p<0.001; and 0.346 (0.256–0.466), p<0.001, respectively. NSAIDs in combination with muscle relaxants and B vitamins versus NSAID monotherapy did not increase the likelihood of pain relief: OR=0.827 (95% CI, 0.594–0.889), p=0.02 and 0.917 (0.804–1.1201), p=0.452, respectively.Conclusion. Meloxicam at a dose of 15 mg/day is an effective and safe drug to treat acute NLBS. Patient gender has no effect on treatment outcome. Age over 65 years, the first NLBS episode, and a good response to NSAIDs in a history are associated with the best treatment results; and severe pain, persistent pain at rest and at night, irradiation to the leg, and lumbar ischialgia are related to the worst result. NSAIDs in combination with muscle relaxants and B vitamins did not improve treatment outcomes.

ОПЫТ ПРИМЕНЕНИЯ ЛАЗЕРНОЙ ВАПОРИЗАЦИИ В ЛЕЧЕНИИ ГРЫЖ МЕЖПОЗВОНКОВЫХ ДИСКОВ В ПОЯСНИЧНОМ ОТДЕЛЕ ПОЗВОНОЧНИКА

The article presents the analysis of effectiveness of laser vaporization for treatment of pain syndrome caused by lumbar disc herniation. We treated 149patients (average age – 40years). 62(41.7%) patients had lumbodynia, 67(45.2%) patients had lumbar ischialgia. Nerve root disorders (radiculopathy, radiculoneuritis) are found in 20(13.1%)patients. 86(57.4%) patients had median hernias of intervertebral disc (disc bulging for 0.6±0.2cm), 36(24.3%) patients had intervertebral disc protrusion and 27(18.3 %) patients had lateral intervertebral hernia (disc bulging for 0.55±0.1 5cm). Satisfactory and good results of laser vaporization are registered in 140(94%) patients with circular protrusion and median hernias with disc bulging up to 7–8mm. Also the decrease in VAS scores of pain syndrome by 2–5points in comparison with initial condition is found. Unsatisfactory results are registered in 9(6%) patients with lateral hernias of more than 5mm and with disease duration more than 6months. Prospective (from 3 to 13months) follow-up was conducted in 49patients. 5 patients from the group with lateral hernias needed open surgeries.

Management of patients with acute lumbodynia and lumbar ischialgia in outpatient settings

Own experience of managing 50 patients (22 men and 28 women) aged 19 to 76 years with acute nonspecific lumbodynia or lumbar ischialgia is described. As anesthesia, patients received etoricoxib (Arcoxia) 60 mg daily and muscle relaxants (Mydocalmum 150--300 mg daily or sirdalud 2--6 mg daily). Patients were informed of the favorable prognosis of the disease and received advice regarding physical activity. The duration of treatment ranged from 14 to 28 days and averaged 20,0 ± 7,9 days. Against the background of treatment, the intensity of pain based on visual analog scale decreased from 6,68 ± 5,23 to 1,10 ± 1,24 points, and disability based on the Roland Morris Disability Questionnaire - from 8,70 ± 6,21 to 1,44 ± 1.98 points; adverse events were not observed. A patient case is described in which positive effect was achieved more quickly than in the previous period of exacerbation after surgical treatment (discectomy). The results demonstrate Arcoxia efficacy and safety in the treatment of acute lumbodynia and lumbar ischialgia.

Parameters of electroneuromyography of lower extremities and densitometry in osteochondrosis of lumbar spine

To study the density of bone tissue and parameters of electroneuromyography (ENMG) in patients with osteochondrosis of lumbar spine. Authors examined 67 patients, mean age 41 years, diagnosed with unilateral lumbar ischialgia syndrome. The changes in the density of bone tissue (osteopenia and osteoporosis) and marked disturbances of neuromuscular apparatus function were found in 79% of the patients. This finding suggests the relationship between the ENMG and densitometry parameters.

Thermoesthesia and algesthesia in the dermatomes of the cauda equina roots in patients with lumbar spinal osteochondrosis

Disorders of thermoesthesia and algesthesia are characteristic of the dermatomes of the cauda equina roots in patients with lumbar spine osteochondrosis. The negative changes in sensitivity are manifested in (1) an increase of the threshold by 2–8 degrees; (2) a decrease of the threshold by 3–6 degrees; (3) the absence of thermal sensitivity. In the presence of reflex syndromes (lumbalgia and lumbar ischialgia), the most severe disorders were in L4, L5, and S1 dermatomes. In patients with radicular syndromes, abnormal thermoesthesia and algesthesia were more pronounced than in patients with the reflex syndromes. Combined conservative therapy resulted in improvement of thermoesthesia and algesthesia mostly in the L5 dermatome of patients with lumbalgia and lumbar ischialgia. Treatment of patients with radicular syndrome did not lead to any significant improvement of the thermal or pain sensitivity of the limb with radiculopathy or in dermatome of the root compressed. More pronounced changes were observed in the contralateral limb.

RESULTS OF TREATMENT OF LUMBAR PAIN SYNDROMES AT OSTEOCHONDROSIS WITH BLUE LIGHT

The authors studied results of treatment of lumbar pain syndromes with blue light (a wavelength of 470 nanometers). The clinico-neurologic observation, neuropsychological testing, an electromyography, rheovasography in terms till 12 months after treatment were carried out. The blue light allows to stop a pain syndrome at 93,3% of patients with a lumbar ischialgia, to enlarge terms of remission and to reduce quantity of exacerbations that leads to improvement of quality of life of patients. Complex treatment of patients with lumbar ischialgia with application of blue light has allowed to receive excellent and good results in 94,4 % of cases, while the same treatment, but without blue light – in 82,9%.

THE INFLUENCE OF COMPLEX CONSERVATIVE TREATMENTON PAIN SEVERITY IN HIP-SPINE SYNDROME

Objective. To study the influence of complex conservative teratment on severity of pain at rest, on movement, and at night in patients with hip-spine syndrome. Material and Methods. Severity of pain was assessed in 18 patients with hip-spine syndrome. Examination was conducted before and at different terms after the complex conservative treatment. Severity of pain syndrome was assessed using digital rating and visual analogous scales. Results. Complex conservative therapy was found to considerably reduce pain at rest, on movement, and at night in the first group of patients with hip-spine syndrome, and this effect remained unchanged at long-term follow-up. In the second group the reduction of pain on movement was rather limited, and pain severity returned to the initial level in a year and a half after the treatment. Conclusion. Complex conservative treatment significantly influences the severity of pain in patients with hip-spine syndrome suffering from coxarthrosis grade 1 and 2 and lumbar osteochondrosis without severe neurological symptoms. The group of patients with coxarthrosis grade 3 and lumbar osteochondrosis with chronic lumbar ischialgia showed lesser reduction in pain scores after the treatment, especially for pain on movement, therefore this group of patients requires more radical treatment.

Correlation between sagittal spinopelvic balance parameters and degenerative changes of the lower lumbar spinal segments

Objective. To study correlation between spinopelvic balance parameters and degenerative changes in the low lumbar spinal segments. Material and Methods. Clinical and radiological findings in 100 patients (32 women, 68 man; mean age 38.7 ± 9.7 years) with chronic lumbodynia and lumbar ischialgia were analysed. Pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT) and global lumbar lordosis (GLL) were measured from lateral radiographs. The severity of degenerative changes in three lower lumbar segments: disk, facet, anterior and posterior supportive columns was assessed using a specially developed scale. The obtained data were statistically processed. Results. It was revealed that disk and anterior supportive column degenerations correlate negatively with parameters of PI, SS and GLL, whereas facet and posterior supportive column degenerations demonstrate positive correlation with the same parameters. Age does not effect disk and anterior supportive column degenerations, but degenerations of facet and posterior supportive column increase severely with age (r = 0.564 and r = 0.467, respectively). Conclusion. Degenerative disc changes predominate in patients with low values of PI, SS, and GLL. Degeneration of facet joints and summaraized severity of posterior supportive column degeneration predominate in patients with high values of PI, SS, and GLL.

Alflutop efficacy in chronic vertebrogenous lumbar ischialgia. A double blind placebo controlled study

Objective. To assess efficacy and safety of intramuscular (im) and paravertebral (pv) alflutop injections in pts with chronic vertebrogenous lumbar ischialgia. Material and methods. 83 pts with lumbar ischialgia syndrome (44 male, 39 female) aged 31 to 56 years (mean 43,1 ±5,2 years) were included. Disease duration varied from I to 7 years (mean 3,5± 1,9 years), duration of the present exacerbation - from 1 to 4 months (mean 2.4±0,8 months). Vertebroneurologic diagnosis was made according to H. Hall criteria. Pts were randomized into 4 groups. 32 pts of group Al received im, 23 pts of group A2 - pv alflutop injections. 14 pts of group Bl and 14 pts of group B2 received im and pv placebo injections respectively. Treatment results were scored by the doctor. Pts assessed spine pain changes on visual analog scale. Quantitative assessment of verbal syndrome was performed with Waddle scale. Results. Im alflutop injections provided good or fair effect in 61%, pv - in 69% of pts (significantly better than placebo). Effect was evident during the first 2 weeks of treatment and persisted for 3 months after its termination. The best results were achieved in pts with facet syndrome, the worst - in spinal stenosis. Drug tolerability was good in both modes of administration.