Lumbosacral Radicular Syndrome Research Articles

Quality of Life in Patients with Lumbosacral Radicular Syndrome and Complete Rehabilitation Program (PRISUM PHSD/1/2022)

Quality of Life in Patients with Lumbosacral Radicular Syndrome and Complete Rehabilitation Program (PRISUM PHSD/1/2022)

Transforaminal pulsed radiofrequency and epidural steroid injection on chronic lumbar radiculopathy: A prospective observational study from a tertiary care hospital in Vietnam.

Lumbosacral radicular syndrome (LRS) is probably the most frequent neuropathic pain syndrome, exaggerating medical and economy burden on developing countries, such as Vietnam. As a result, the urgence to find an approach which is both affordable and effective always puts great demand on medical researchers. Evaluate the effectiveness of transforaminal pulsed radiofrequency (PRF) stimulation on the dorsal root ganglion (DRG) and epidural steroid injection (ESI) in management of chronic lumbosacral radiculopathy. Seventy-six patients with chronic radicular pain were performed transforaminal PRF + ESI by neurosurgeons. Demographic characteristics and surgical outcomes were recorded on admission, pre-procedural and post-procedural for 1-month, 3-month, 6-month and 12-month follow-up. Primary outcome was measured by using Visual Analogue Scale (VAS), Oswestry disability index (ODI) and Straight Leg Raising Test (SLRT). Secondary outcome was subjectively collected based on short assessment of patients' satisfaction (SAPS). Patients who received transforaminal PRF and ESI showed significant improvements on all three evaluation tools (VAS, ODI, SLRT), compared to that before treatment (p<0.001). Pain relief was achievable and long-lasting, which met patients' expectation. No significant complications were observed for 12 months follow-up. Transforaminal PRF combined with ESI in management of lumbosacral radiculopathy should be a good method of choice for its effectiveness and safety in management of pain.

Assessment of the effect of pulsed currents and vibration therapy on the quality of life in patients with lumbosacral dorsopathy

Constant pain in the back leads to chronicity of the process and disability of the population. This work intends to develop and scientifically substantiate comprehensive treatment of lumbosacral dorsopathy patients with radicular syndrome in the subacute stage of the disease, including drug therapy, multichannel electrical stimulation with bipolar pulsed currents (MES BPC), and vibration massage, as well as to evaluate the impact of this treatment on the overall indicator of quality of life in patients. Results. Before treatment, the patients with lumbosacral dorsopathy and radicular syndrome in the subacute stage of the disease in the 1st (control) and 2nd (study) groups had significantly lower QOL indicators than normative ones, which reflected a decrease in quality of life. Complex treatment, including drug therapy, MES BPC, and vibration massage, contributed to a more pronounced and persistent improvement in the quality of life indicator in the patients of the 2nd (study) group throughout all periods of observation, compared with standard drug therapy in the 1st (control) group of the patients.

Management of low back pain and lumbosacral radicular syndrome: the Guideline of the Royal Dutch Society for Physical Therapy (KNGF).

Significant progress and new insights have been gained since the Dutch Physical Therapy guideline on low back pain (LBP) in 2013 and the Cesar en Mensendieck guideline in 2009, necessitating an update of these guidelines. To update and develop an evidence-based guideline for the comprehensive management of LBP and lumbosacral radicular syndrome (LRS) without serious specific conditions (red flags) for Dutch physical therapists and Cesar and Mensendieck Therapists. Clinical practice guideline. Inpatient and outpatient. Adults with LBP and/or LRS. Clinically relevant questions were identified based on perceived barriers in current practice of physical therapy. All clinical questions were answered using published guidelines, systematic reviews, narrative reviews or systematic reviews performed by the project group. Recommendations were formulated based on evidence and additional considerations, as described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. Patients participated in every phase. The guideline describes a comprehensive assessment based on the International Classification of Functioning, Disability and Health (ICF) Core Set for LBP and LRS, including the identification of alarm symptoms and red flags. Patients are assigned to three treatment profiles (low, moderate and high risk of persistent symptoms) based on prognostic factors for persistent LBP. The guideline recommends offering simple and less intensive support to people who are likely to recover quickly (low-risk profile) and more complex and intensive support to people with a moderate or high risk of persistent complaints. Criteria for initiating and discontinuing physical therapy, and referral to a general practitioner are specified. Recommendations are formulated for information and advice, measurement instruments, active and passive interventions and behavior-oriented treatment. An evidence based physical therapy guideline for the management of patients with LBP and LRS without red flags for physical therapists and Cesar and Mensendieck therapists was developed. Cornerstones of physical therapy assessment and treatment are risk stratification, shared decision-making, information and advice, and exercises. This guideline provides guidance for clinicians and patients to optimize treatment outcomes in patients with LBP and LRS and offers transparency for other healthcare providers and stakeholders.

Efficacy of epidural infiltration in the management of pain and disability due to acute and subacute lumbosacral radiculopathy

Background and ObjectiveEpidural infiltrations are used for treatment of low back pain and sciatica. Linked to lumbar radiculopathy (lumbosacral radicular syndrome). This study evaluates the efficacy of epidural infiltration by different routes to reduce pain intensity, disability and return to work. MethodsIs a prospective observational study in one hundred consecutive patients sent to pain unit for severe lumbo-sacral radiculopaty. We analyze the efficacy on pain relief (Visual Analogue Scale) and funcional status at two weeks, one month, and three months after epidural injection of local anesthetics and esteroids with differents approachs (interlaminar, caudal and transforaminal). ResultsNinety nine patients (46.5% men, 53.5 women) were finally enrrolled in the study. Mean age was 57.47 ± 11.1 years. The caudal approach was used in 58.6% patients, 23.2% transforaminal approach, and 18.2% interlaminar approach. A significant pain relief was found in all times studied (EAV 7.48 ± 1.5 basal; 6.2 ± 0,9 at 15 days; 6.3 ± 1.2 at one month; 6.15 ± 1.3 at 3 months, p < 0.05). Transforaminal approach was superior to caudal or interlaminal. Seventy percent in time off work patients returned to work after epidural inyections. ConclusionsEpidural local anesthetics with esteroids injections for lumbo-sacral radiculopathy were effective for low back pain, improved functional status and promoted return to work. Transforaminal approach is superior to others.

Eficacia de las infiltraciones epidurales en el abordaje del dolor y la discapacidad por radiculopatía lumbosacra aguda y subaguda

Backgrund and objectiveEpidural infiltrations are used for treatment of low back pain and sciatica. linked to lumbar radiculopathy (lumbosacral radicular syndrome). This study evaluates the efficacy of epidural infiltration by different routes to reduce pain intensity, disability and return to work. MethodsIs a prospective observational study in one hundred consecutive patients sent to pain unit for severe lumbo-sacral radiculopaty. We analyze the efficacy on pain relief (Visual Analogue Scale) and funcional status at two weeks, one month, and three months after epidural injection of local anesthetics and esteroids with differents approachs (interlaminar, caudal and transforaminal). ResultsNinety nine patients (46.5% men, 53.5 women) were finally enrrolled in the study. Mean age was 57.47±11.1 years. The caudal approach was used in 58.6% patients, 23.2% transforaminal approach, and 18.2% interlaminar approach. A significant pain relief was found in all times studied (EAV 7.48±1.5 basal; 6.2±0,9 at 15 days; 6.3±1.2 at one month; 6.15±1.3 at 3 months, P<.05). Transforaminal approach was superior to caudal or interlaminal. Seventy percent in time off work patients returned to work after epidural inyections. ConclusionsEpidural local anesthetics with esteroids injections for lumbo-sacral radiculopathy were effective for low back pain, improved functional status and promoted return to work. Transforaminal approach is superior to others.

A Health-Impact Assessment of an Ergonomic Measure to Reduce the Risk of Work-Related Lower Back Pain, Lumbosacral Radicular Syndrome and Knee Osteoarthritis among Floor Layers in The Netherlands

Sand-cement-bound screed floor layers are at risk of work-related lower back pain, lumbosacral radicular syndrome and knee osteoarthritis, given their working technique of levelling screed with their trunk bent while mainly supported by their hands and knees. To reduce the physical demands of bending of the trunk and kneeling, a manually movable screed-levelling machine was developed for floor layers in the Netherlands. The aim of this paper is to estimate the potential health gains of working with a manually movable screed-levelling machine on the risk of lower back pain (LBP), lumbosacral radicular syndrome (LRS) and knee osteoarthritis (KOA) compared to traditional working techniques. This potential health gain was assessed using the epidemiological population estimates of the Population Attributable Fraction (PAF) and the Potential Impact Fraction (PIF), combined with work-related risk estimates for these three disorders from systematic reviews. The percentage of workers exceeding these risk estimates was based on worksite observations among 28 floor layers. For LBP, 16/18 workers were at risk when using traditional working techniques, with a PAF = 38%, and for those using a manually movable screed-levelling machine, this was 6/10 with a PIF = 13%. For LRS, these data were 16/18 with a PAF = 55% and 14/18 with a PIF = 18%, and for KOA, 8/10 with a PAF = 35% and 2/10 with a PIF = 26%. A manually movable screed-levelling machine might have a significant impact on the prevention of LBP, LRS and KOA among floor layers in the Netherlands, and health-impact assessments are a feasible approach for assessing health gains in an efficient way.

OP06 Percutaneous Transforaminal Endoscopic Discectomy: From Insufficient Evidence To Reimbursement

IntroductionThe standard surgical technique for lumbosacral radicular syndrome in the Netherlands is open microdiscectomy (OM). An alternative technique, preferred by some Dutch physicians, is percutaneous transforaminal endoscopic discectomy (PTED). However, in 2006 the Dutch National Health Care Institute (Zorginstituut Netherland [ZIN]) concluded that the available evidence was insufficient, and a high quality randomized controlled trial (RCT) was needed to assess the cost-effectiveness of PTED compared to OM. The relevant physician group agreed with this conclusion, but they were unable to perform this RCT due to lack of funding and high treatment costs.MethodsIn 2012, the Netherlands introduced a conditional reimbursement (CR) program to give patients earlier access to promising treatments. Researchers, in collaboration with physicians and patients, submitted a grant proposal and in 2016 the Dutch Ministry of Health approved the CR of PTED. Due to this decision, insurance companies were obliged to reimburse PTED for patients participating in the PTED-study (NCT02602093). The Netherlands Organization for Health Research and Development (ZonMw) also provided a research grant to fund the PTED-study. In total, 682 adult patients with greater than 10 weeks of radiating pain, or greater than 6 weeks of excessive radiating pain and an indication for surgery were included. After 4 years and 5 months the PTED-study was completed.ResultsOutcomes of published studies and the unpublished PTED-study were used in the HTA reassessment. Results showed that PTED was noninferior to OM with regards to leg pain (Visual Analogue Scale: mean difference (MD) -0.73; 95% confidence interval [CI] -5.04, 3.59), functional status (Oswestry Disability Index: MD -2.07; 95% CI -3.61, -0.53), and rate of complications (relative risk 0.45; 95% CI 0.18, 1.12) after 6 months (GRADE level ‘moderate’). Furthermore PTED was, after the surgeons’ learning-curve, cost-effective.ConclusionsThis CR project was successful and PTED is now reimbursed as part of the Dutch healthcare package. However, in order to maintain high quality care in clinical practice, safeguards should be developed (including the appropriate training of surgeons). This example shows that CR programs are essential for promising treatments without ‘wealthy’ manufacturers. Additionally, all stakeholders are needed to make a CR-study successful.

Occupational recovery of Dutch workers with low back pain.

BackgroundLow back pain (LBP) is a world leading cause of disability and has substantial impact on individuals and society as a whole. The largest part of the societal burden of LBP is caused by indirect costs, including sick leave.AimsWe aimed to describe occupational recovery and associated costs for workers consulting an occupational physician (OP) with LBP, and to determine to what extent this differs by diagnoses: non-specific favourable LBP, non-specific unfavourable LBP, lumbosacral radicular syndrome (LRS) and specific LBP.MethodsWe analysed longitudinal dynamic cohort data from an occupational health service, representing ~1.2 million workers from various companies and sectors throughout the Netherlands. The OP registered data on sick leave and LBP diagnoses. A survival analysis was performed on sick leave duration to determine recovery and a linear regression analysis on cost per episode, adjusting for sex, age and working hours.ResultsWe analysed 5951 LBP episodes from 5472 workers who consulted an OP, with a median and mean duration sick leave of 95 and 151 days, respectively. The probability of not recovering was 82% at 30 days and 10% at 1 year. The mean cost per episode was €15 350. Specific LBP (€22 999; beta (95% confidence interval [CI]): 16 278 (13 325–19 165)) and LRS (€20 111; beta (95% CI): 13 589 (12 527–14 659)) had the longest and most costly episodes, compared to non-specific favourable LBP (€6745; reference group).ConclusionsWith LRS and non-specific unfavourable LBP accounting for over 83% of LBP-associated sick leave costs, the work-directed care of workers with these two diagnoses deserves increased attention.

Microdiscectomy for sciatica: reality check study of long-term surgical treatment effects of a Lumbosacral radicular syndrome (LSRS).

It remains unclear whether the long-term results of RCTs regarding the outcome of microdiscectomy for lumbosacral radicular syndrome (LSRS) are generalizable. The purpose of this study was to determine the external validity of the outcome preseneted in RCTs after microdicectomy for LSRS in a patient cohort from a high-volume spine center. Between 2007 and 2010, 539 patients had a single level microdiscectomy for MRI disk-related LSRS of whom 246 agreed to participate. Questionnaires includedvisual analogue scores (VAS) for leg pain, RDQ, OLBD, RAND-36 and Likert scores for recovery, leg and back pain. Lumbar re-operation(s) were registered. Mean age was 51.3, and median time of follow-up was 8.0years. Re-operation occurred in 64 (26%) patients. Unfavorable perceived recovery was noted in 85 (35%) patients, and they had worse leg and back pain than the 161 (65%) patients with a favorable recovery: median VAS for leg pain 28/100mm versus 2/100mm and median VAS for back pain 9/100mm versus 3/100mm, respectively. In addition, the median RDQ and OLBD scores differed significantly: 9 vs 3 for RDQ and 26 vs 4 for OLBD, respectively (p < 0.001). In this cohort study, the long-term results after microdiscectomy for LSRSwere less favorable than those obtained in RCTs, possibly caused by less strict patient selection than in RCTs. Our findings emphasize that patients, who do not meet the same inclusion criteria for surgery as in RCTs, should be informed about the chances of a less favorable result.

The Lead of Direct Adjuvant Intraoperative Foraminal Steroids' Infiltration.

Low back pain generally involves lumbosacral radicular syndrome, nerve root pain, and nerve root entrapment/irritation. Management options for patients are variable and diverging. To the highlight the efficacy of combined early decompressive surgery plus intraoperative steroid injections in terms of postoperative back pain in patients managed by our combined team. A prospective study conducted by reviewing all consecutive patients managed, over a 1-year period (2018-2019). This study showed that adjunct use of intraoperative foraminal and epidural steroids injections to treat back pain in patients with degenerative spine disease could significantly improve the pain score which leads to significant decrease in working days off and the need for pain killer medications or even obviating the usage rate.

Towards harmonisation of case definitions for eight work-related musculoskeletal disorders - an international multi-disciplinary Delphi study

BackgroundInternational consensus is needed on case definitions of work-related musculoskeletal disorders and diseases (MSDs) for use in epidemiological research. We aim to: 1) study what information is needed for the case definition of work-related low back pain (LBP), lumbosacral radicular syndrome (LRS), subacromial pain syndrome (SAPS), carpal tunnel syndrome (CTS), lateral and medial elbow tendinopathy, and knee and hip osteoarthritis, and to 2) seek consensus among occupational health professionals/researchers regarding the case definitions of these work-related MSDs.MethodsA two-round Delphi study was conducted with occupational health professionals/researchers from 24 countries. Definition of work-related MSDs were composed of a case definition with work exposures. Round 1 included 32 case definitions and round 2, 60 case definitions. After two rounds, consensus required 75% of the panellists to rate a case definition including work exposures ≥7 points on a 9-point rating scale (completely disagree/completely agree).ResultsFifty-eight panellists completed both rounds (response rate 90%). Forty-five (70%) panellists thought that for LBP a case definition can be based on symptoms only. Consensus was only reached for work-related medial elbow tendinopathy, while the lowest agreement was found for knee osteoarthritis. Where consensus was not reached, this was – except for LBP - related to physical examination and imaging rather than disagreement on key symptoms.ConclusionConsensus on case definitions was reached only for work-related medial elbow tendinopathy. Epidemiological research would benefit from harmonized case definitions for all MSDs including imaging and physical examination for LRS, SAPS, CTS, lateral elbow tendinopathy and hip and knee osteoarthritis.

Feasibility and surgical technique of percutaneous transforaminal discectomy for the treatment of lumbar disc herniation

Percutaneous transforaminal endoscopic discectomy (PTED) is an alternative minimally invasive technique for the treatment of lumbosacral radicular syndrome resulting from lumbar disc herniation. The latter is performed with the help of local anesthesia and sedation in an awake patient with the advantage of direct feedback. Access to the target is lateral and follows a safe trajectory through the Kambin triangle. The main advantages of this surgical technique are the possibility of early discharge within 2 hours after its completion, negligible blood loss, lower risk of infectious complications, convenience in patients with obesity, reduced risk of epidural fibrosis. There are currently no large randomized trials of good quality demonstrating the advantage of PTED over open interlaminar access established in practice. In the worst case, endoscopic discectomy is not known to pose additional risks to patients. The operative technique with a clinical case and a discussion about the applicability of the new approach for the treatment of lumbar disc herniations are presented.

Clinical Relevance of Epidural Steroid Injections on Lumbosacral Radicular Syndrome-related Synptoms: Systematic Review and Meta-Analysis.

Epidural steroid injections (ESIs) can be used to reduce lumbosacral radicular syndrome (LRS) related pain. The clinical relevance of ESIs are currently unknown. This systematic review and meta-analyses aims to assess whether ESIs are clinically relevant for patients with LRS. Comprehensive literature searches for randomized controlled trials regarding steroid injections for LRS were conducted in PudMed, EMBASE, CINAHL, and CENTRAL from their inception to September 2018 (December 2019 for PubMed). For each homogenous comparison, the outcomes function, pain intensity and health-related quality of life at different follow-up intervals were pooled separately. The GRADE approach was used to determine the overall certainty of the evidence. Seventeen studies were included. Two different homogenous comparisons were identified for which the randomized controlled trials could be pooled. In 36 of the 40 analyses no clinically relevant effect was found. The certainty of evidence varied between very low to high. Four analyses found a clinically relevant effect, all on pain intensity and health-related quality of life, but the certainty of the evidence was either low or very low. Two of the 33 subgroup analyses showed a clinically relevant effect. However, according to the GRADE approach the certainty of these findings are low to very low. On the basis of the analyses we conclude there is insufficient evidence that ESIs for patients with LRS are clinically relevant at any follow-up moment. High-quality studies utilizing a predefined clinical success are necessary to identify potential clinically relevant effects of ESIs. Until the results of these studies are available, there is reason to consider whether the current daily practice of ESIs for patients with LRS should continue.

Diagnostic criteria for musculoskeletal disorders for use in occupational healthcare or research: a scoping review of consensus- and synthesised-based case definitions

BackgroundThe aim of this study was to identify case definitions of diagnostic criteria for specific musculoskeletal disorders (MSDs) for use in occupational healthcare, surveillance or research.MethodsA scoping review was performed in Medline and Web of Science from 2000 to 2020 by an international team of researchers and clinicians, using the Arksey and O’Malley framework to identify case definitions based on expert consensus or a synthesis of the literature. Seven MSDs were considered: non-specific low back pain (LBP), lumbosacral radicular syndrome (LRS), subacromial pain syndrome (SAPS), carpal tunnel syndrome (CTS), lateral or medial elbow tendinopathy, and knee and hip osteoarthritis (OA). Case definitions for occupational healthcare or research were charted according to symptoms, signs and instrumental assessment of signs, and if reported, on work-related exposure criteria.ResultsIn total, 2404 studies were identified of which 39 were included. Fifteen studies (38%) reported on non-specific LBP, followed by knee OA (n = 8;21%) and CTS (n = 8;21%). For non-specific LBP, studies agreed in general on which symptoms (i.e., pain in lower back) and signs (i.e., absence of red flags) constituted a case definition while for the other MSDs considerable heterogeneity was found. Only two studies (5%), describing case definitions for LBP, CTS, and SAPS and lateral and medial elbow tendinopathy respectively, included work-related exposure criteria in their clinical assessment.ConclusionWe found that studies on non-specific LBP agreed in general on which symptoms and signs constitute a case definition, while considerable heterogeneity was found for the other MSDs. For prevention of work-related MSDs, these MSD case definitions should preferably include work-related exposure criteria.

Genome-wide association studies of low back pain and lumbar spinal disorders using electronic health record data identify a locus associated with lumbar spinal stenosis.

Identifying genetic risk factors for lumbar spine disorders may lead to knowledge regarding underlying mechanisms and the development of new treatments. We conducted a genome-wide association study involving 100,811 participants with genotypes and longitudinal electronic health record data from the Electronic Medical Records and Genomics Network and Geisinger Health. Cases and controls were defined using validated algorithms and clinical diagnostic codes. Electronic health record-defined phenotypes included low back pain requiring healthcare utilization (LBP-HC), lumbosacral radicular syndrome (LSRS), and lumbar spinal stenosis (LSS). Genome-wide association study used logistic regression with additive genetic effects adjusting for age, sex, site-specific factors, and ancestry (principal components). A fixed-effect inverse-variance weighted meta-analysis was conducted. Genetic variants of genome-wide significance (P < 5 × 10-8) were carried forward for replication in an independent sample from UK Biobank. Phenotype prevalence was 48.8% for LBP-HC, 19.8% for LSRS, and 7.9% for LSS. No variants were significantly associated with LBP-HC. One locus was associated with LSRS (lead variant rs146153280:C>G, odds ratio [OR] = 1.17 for G, P = 2.1 × 10-9), but was not replicated. Another locus on chromosome 2 spanning GFPT1, NFU1, and AAK1 was associated with LSS (lead variant rs13427243:G>A, OR = 1.10 for A, P = 4.3 × 10-8) and replicated in UK Biobank (OR = 1.11, P = 5.4 × 10-5). This was the first genome-wide association study meta-analysis of lumbar spinal disorders using electronic health record data. We identified 2 novel associations with LSRS and LSS; the latter was replicated in an independent sample.

The effect of laser phoresis of biologically active substances on microcirculation in paravertebral muscles in the radicular syndrome of the lumbosacral spine

In the case of radicular syndrome in patients with dorsopathy, degenerative dystrophic changes, which contribute to the creation of additional mechanisms of pain impulse and chronization of the pathological process, are diagnosed in the deep muscles. The study included 40 patients with dorsopathy of the lumbosacral spine and radicular syndrome, with the average age of 45,3±1,5years, who were divided into 2 groups comparable in age and clinical and functional characteristics: the main group of 20 patients who were treated with laser phoresis of biologically active substances and the control group of 20 patients who received standard pharmacotherapy. As a result of the study, a significantly more pronounced improvement in the state of microcirculation in the paravertebral muscles when using phytoextracts laser phoresis was proved, which was confirmed by radiothermometry and transcutaneous oximetry. The analysis of radiothermometry and oximetry parameters obtained 3 months after the end of the course showed the stability of the therapeutic effect in 96% of patients in the main group, while in the control group, 50% of patients showed a regression of the effect obtained as a result of treatment. In longer terms, the therapeutic effect in 90% of patients of the main group was maintained for 9–12 months of follow-up, while in the control group — no more than 3–4 months.

SCIATICA (IRQ-UN-NASA) IN MODERN AND UNANI PERSPECTIVE

Sciatica is a type of neuropathic pain and commonest variation of low back pain. It is known by a range of terms in the literature, such as lumbo sacral radicular syndrome, radiculopathy, nerve root pain and nerve root entrapment or irritation etc. The intense leg pain may be accompanied by neurological changes of muscle weakness and wasting, sensory changes in the nerve root distribution. There may be intra-spinal, intra-pelvic and extra-pelvic causes compressing the nerve and producing inflammation. In Unani medicine the term “Irq-un-Nasa” is used to describe such pain that initiates from lower back and radiates up 4,5 to knee or ankle joint posterolaterally. Most of the Unani scholars have mentioned it as a subtype of Wajaul Mafasil. The most common cause is the infiltration (nufooz) of abnormal homours in the fluid of hip joint, such as Ghair tabayi Balgham, Safra or Dam or admixture of Balgham and Safra, such infiltration for a prolonged period result into Tahajjur-e-Mafasil and even Irq-un-Nasa. Whenever the nerve becomes weak due to any reason the susceptibility for the accumulation of any morbid matter is increased. There may be sue mizaj damwi/ safravi/ balghami/ saudawi as active cause of Irq-un-Nasa. By now it is understood that this is the disease of nerve, and it is diagnosed and managed accordingly.

Cost‐effectiveness of combination therapy (Mechanical Diagnosis and Treatment and Transforaminal Epidural Steroid Injections) among patients with an indication for a Lumbar Herniated Disc surgery: Protocol of a randomized controlled trial

ObjectivesThe general consensus is that surgical treatment is advised when conservative methods fail in patients with lumbosacral radicular syndrome (LRS). Preliminary evidence from our pilot study indicates that combination therapy (mechanical diagnosis therapy and transforaminal epidural injections) can prevent surgical treatment in patients on the waiting list for surgery. The pilot study lacked a control group, and therefore, firm conclusions pertaining to effects could not be made. This study aims to determine if combination therapy, performed while being on the waiting list for lumbar herniated disc surgery, is effective and cost‐effective compared with usual care (i.e., no intervention while being on the waiting list) among patients with a magnetic resonance imaging (MRI)‐confirmed indication for a lumbar herniated disc surgery.MethodsA randomized controlled trial will be conducted with an economic evaluation. Patients aged 18 and above with incapacitating LRS, with leg pain and an MRI confirmed indication for lumbar disc hernia surgery, will be recruited from seven Dutch hospitals. While being on the waiting list for lumbar herniated disc surgery, patients will be randomized to either the combination therapy or usual care group. The primary outcome measure is the number of patients undergoing lumbar disc surgery during 12‐month follow‐up. Secondary outcomes include back and leg pain intensity (numeric pain rating scale), physical functioning (Roland Morris Disability Questionnaires‐23), self‐perceived recovery (global perceived effect), and health‐related quality of life (EuroQol Five Dimensions Health Questionnaire (EQ‐5D‐5L) and 12‐Item Short Form Health Survey (SF‐12)). For the economic evaluation, societal and health care costs will be measured. Measurements moments are baseline, 1, 2, 4, 6, 9, and 12 months. Data will be analysed according to the intention‐to‐treat principle.ConclusionNo randomized controlled trials have evaluated the effectiveness and cost‐effectiveness of combination therapy compared with usual care in patients with an indication for lumbar herniated disc surgery, which emphasizes the importance of this study.

Implementation of web-based hospital specialist consultations to improve quality and expediency of general practitioners\u2019 care: a feasibility study

BackgroundRising healthcare costs due to unnecessary referrals to secondary healthcare services underscore the need for optimizing current referral procedures. This study investigates whether the use of web-based consultation (WBC) in general practice is a feasible alternative to decrease referrals.MethodsPatients with lumbosacral radicular syndrome, knee complaints, or thyroid dysfunction, who visited the general practitioner (GP) between May 2015 and December 2016 were included for a WBC. We determined whether the GP would refer a patient to an outpatient clinic in the absence of a WBC and then compared this decision with the referral advice from a specialist. We further assessed the user-friendliness of the WBC service based on average recorded user time and feedback from the GPs.ResultsSeventy eligible WBCs submitted by GPs were analyzed. Our data showed a 46% absolute reduction in in-persons referrals in our study population. These findings confirmed the feasibility of using WBC. The median time spent to submit a WBC was five and 10 min for GPs and specialists respectively. On average, the WBC service saved €286 per WBC. The results of a questionnaire showed that GPs found WBC to be a user-friendly option which could help reduce the number of in-person referrals.ConclusionWe demonstrated that WBC is not only feasible but has the potential to reduce nearly half of all in-person referrals to outpatient clinics. WBC decreased healthcare expenses and proved to be a user-friendly and safe alternative to the standard referral process. WBC may potentially have a profound impact on healthcare expenditure if applied in a wider medical setting. For follow-up research, we recommend including a control group for comparative analyses.