Nerve Root Involvement Research Articles

Assessing neuropathic pain in patients with low back‐related leg pain: Comparing the painDETECT Questionnaire with the 2016 NeuPSIG grading system

Low back-related leg pain with nerve root involvement is conceptually regarded as a neuropathic condition. However, it is uncertain to what extent patients with this condition can be formally classified with neuropathic pain. First, we used the 2016 revision of the IASP Special Interest Group on Neuropathic Pain (NeuPSIG) grading system for neuropathic pain to grade patients suffering from low back-related leg pain and a corresponding disc herniation with either unlikely, possible, probable or definite neuropathic pain. Examination included bedside quantitative sensory testing. Next, we used the clinical classification based on the 2016 NeuPSIG grading system as a reference standard to assess the ability of the painDETECT Questionnaire to identify patients with neuropathic pain. Of the 50 included patients, six (12%) fulfilled the clinical classification criteria for probable and 44 (88%) for definite neuropathic pain, while none were graded unlikely or possible. According to painDETECT, 23 patients (46%) were classified with unlikely neuropathic pain, 18 patients (36%) had an uncertain condition and in nine patients (18%) neuropathic pain was likely. Among the 44 patients graded as having definite neuropathic pain by the clinical classification, eight were classified as likely neuropathic pain by painDETECT, resulting in an agreement of 18%. Of these 44 patients graded with definite neuropathic pain, painDETECT classified 21 patients (48%) as unlikely and 15 (34%) as uncertain. Our results do not support the use of painDETECT as a screening tool to classify or grade neuropathic components in patients with low back-related leg pain. The painDETECT Questionnaire performed poorly at detecting neuropathic pain among patients with low back-related leg pain, compared to clinical examination based on the 2016 NeuPSIG grading system as a reference standard. Our results do not support the use of painDETECT as a screening tool to classify or grade neuropathic components in this population.

Inflammatory demyelinating polyneuropathy versus leptomeningeal disease following Ipilimumab

BackgroundIpilimumab is an FDA-approved anti-CTLA-4 monoclonal antibody used in treatment of metastatic melanoma. We present an unusual neurological complication of Ipilimumab therapy and the diagnostic dilemma it caused.Case presentationA 42 year old male with Stage IV metastatic melanoma developed lower extremity weakness and sensory neuropathy following three doses of Ipilimumab. MRI of the lumbar spine was initially interpreted as diffuse leptomeningeal disease, and patient began Dexamethasone and radiation with improvement in symptoms. However, subsequent completion imaging revealed smooth nerve root involvement with sparing of the spinal cord, findings more compatible with inflammatory demyelinating polyneuropathy. The absence of malignant cells in the cerebrospinal fluid (CSF) and nerve conduction study (NCS) showing lumbar polyradiculoneuropathy with axonal involvement and demyelinating features supported the diagnosis of inflammatory demyelinating polyneuropathy. Later in the course of his disease, the patient developed frank leptomeningeal melanoma.ConclusionIpilimumab immune-related toxicity presented as inflammatory demyelinating polyneuropathy, which was difficult to distinguish from leptomeningeal disease, a common complication of melanoma.

Novel approach to characterising individuals with low back-related leg pain: cluster identification with latent class analysis and 12-month follow-up.

Traditionally, low back-related leg pain (LBLP) is diagnosed clinically as referred leg pain or sciatica (nerve root involvement). However, within the spectrum of LBLP we hypothesised that there may be other, unrecognised patient subgroups. This study aimed to identify clusters of LBLP patients using latent class analysis (LCA) and describe their clinical course.The study population were 609 LBLP primary care consulters. Variables from clinical assessment were included in the LCA. Characteristics of the statistically identified clusters were compared and their clinical course over one year was described.A five cluster solution was optimal. Cluster 1 (n=104) had mild leg pain severity and was considered to represent a referred leg pain group with no clinical signs suggesting nerve root involvement (sciatica). Cluster 2 (n=122), cluster 3 (n=188) and cluster 4 (n=69) had mild, moderate and severe pain and disability respectively and response to clinical assessment items suggested categories of mild, moderate and severe sciatica. Cluster 5 (n=126) had high pain and disability, longer pain duration, more comorbidities and was difficult to map to a clinical diagnosis.Most improvement for pain and disability was seen in the first four months for all clusters. At 12 months the proportion of patients reporting recovery ranged from 27% for cluster 5 to 45% for cluster 2 (mild sciatica).This is the first study that empirically shows the variability in profile and clinical course of patients with LBLP including sciatica. More homogenous groups were identified which could be considered in future clinical and research settings.

A Consecutive Series of 39 Microendoscopic Discectomies for Recurrent Lumbar Disc Herniation

Background Data: Interlaminar microendoscopic discectomy (MED) for treatment of primary lumbar disc herniation is a fairly established technique in clinical practice. However, in recurrent cases, a concern is raised that anatomy has been distorted thus endoscopic intervention may carry greater risks of morbidity.Purpose: In the present study, the authors report their seven years’ experience with posterior interlaminar MED in recurrent lumbar disc herniation (RLDH), highlighting the surgical technique, its outcome and feasibility.Study Design: A retrospective clinical case study.Patients and Methods: In the period between May, 2009 and July, 2016, 39 consecutive patients with symptomatic RLDH as confirmed by clinical examination, magnetic resonance imaging (MRI) and computed tomography (CT) scan underwent posterior interlaminar MED. Mean age was 39.7 years, range: (29-56 years). The approach was similar to a standard interlaminar MED. Patients were followed-up for 7 years (mean follow-up was 47.9 months, range: 3 – 83 months). Clinical outcomes were reviewed and evaluated in terms of pain Visual Analogue Scale (VAS) and Modified Macnab criteria (MMC).Results: Mean operative time was 97 minutes (range: 59–155 min.) with a mean blood loss of 57 ml and an approximate hospital stay of 22.5 hours. There were no new postoperative neurological deficits or major complications. At initial follow-up, according to MMC (3months postoperative) 67% of patients were pain free (26/39) and considered their postoperative status as excellent, 24% as good (9/39), and 8% (3/39) as fair, whereas one patient was unsatisfied. Intraoperatively, there were 3 patients of dural tears, mainly toward the beginning of our study, seven patients of accidental medial facetectomies due to excess bony work and two patients had an unintended fracture of the base of the spine. Postoperatively, 2 patients had temporary weakness of involved root that resolved on follow-up and three patients had transient postoperative neuralgia.Conclusion: Recurrent lumbar disc herniation can be treated safely and adequately with posterior interlaminar MED although of partial loss of anatomy. The technique is associated with satisfactory clinical results as well as short hospital stay. It provides adequate visualization and decompression of the involved nerve root. (2017ESJ127)

Surgical placement of rectus sheath catheters in a cadaveric cystectomy model.

Introduction Surgically inserted rectus sheath catheters (RSCs) are used increasingly for analgesia after cystectomy and other abdominal surgery. Currently, there is little information on the optimal positioning of RSCs to allow maximal spread of local anaesthetic. This study sought to assess the spread of dye injected via RSCs and to highlight the extent of its coverage in a fresh unembalmed cadaveric cystectomy model in order to confirm the nerve endings that are likely to be anaesthetised with RSCs. Methods Four cadavers underwent lower midline incision with limited bladder mobilisation. A RSC was inserted into the eight hemiabdomens. The RSCs were positioned either anterior (n=5) or posterior to the rectus muscle (n=3). Dye was injected down the RSCs to evaluate spread. The eight hemiabdomens were dissected anatomically to determine the surface area of dye spread and nerve root involvement. Results The mean surface area of dye spread with anteriorly placed RSCs was 30.6cm2 anterior and 25.9cm2 posterior to the rectus muscle. The mean surface area of dye spread with posteriorly placed RSCs was 11.3cm2 anterior and 37.3cm2 posterior to the rectus muscle. The mean number of nerve roots stained with anteriorly and posteriorly placed RSCs was 3.8 and 2.7 respectively. Subcutaneous spread of dye was seen with one anterior RSC insertion. Peritoneal spread was seen with one anteriorly positioned RSC. Conclusions This study has demonstrated efficient nerve root infiltration with anteriorly and posteriorly positioned RSCs. It appears that dye spreads between the fibres of the rectus muscle rather than out laterally to the nerve roots when spreading from its initial compartment.

A rare case of lumbosacral myeloradiculitis in aquaporin-4 antibody positive neuromyelitis optica spectrum disorder following varicella zoster infection

Background: Neuromyelitis optica (NMO) is a severe demyelinating CNS disorder traditionally causing simultaneous bilateral optic neuritis and transverse myelitis. The discovery of the highly specific aquaporin-4 autoantibody has led to increased understanding of pathogenesis and the recognition of a broader neuromyelitis optica spectrum disorder (NMOSD). Whilst the diagnostic criteria for NMOSD has been revised to include involvement of CNS regions other than the optic nerve and spinal cord, nerve root involvement is not widely recognised.

Functional Outcome After Resection of Von Hippel-Lindau Disease-Associated Cauda Equina Hemangioblastomas: An Observational Cohort Study.

Cauda equina hemangioblastomas in von Hippel-Lindau (VHL) disease can cause significant neurological signs and symptoms. Despite their associated morbidity, the management of these tumors remains incompletely defined. To determine optimal management, we analyzed the functional outcomes after resection of these tumors. VHL patients who underwent surgical resection of cauda equina hemangioblastomas at the National Institutes of Health and the University of Virginia were included. Clinical and radiological follow-up was performed at 6- to 12-month intervals after surgery. Fifteen patients underwent 18 operations for 21 cauda equina hemangioblastomas (median follow-up 5.9 years). Patients often presented with multiple symptoms, including pain (67%), numbness (50%), urinary complaints (33%), and weakness (11%). Median preoperative tumor volume was 1.2 cm 3 . Four tumors at 3 operations were not resected due to a motor nerve root origin. Gross total resection was achieved in 14 surgeries (93% of operations when resection was attempted). New mild (non-function limiting) neurological symptoms were noted after 11 operations (61%), which most often (64%) resolved within 2 weeks of surgery. At 6-month follow-up, 15 patients (83%) were stable, 2 (11%) were improved, and 1 (6%) was worse. Histological analysis revealed that all tumors originated from within the involved nerve fascicle. VHL-associated cauda equina hemangioblastomas have an intrafascicular origin and require interruption of the rootlet of origin for complete resection. Motor nerve root involvement may preclude complete resection but strategies including bony decompression and/or interruption of vascular supply may provide a therapeutic option. Nevertheless, most VHL patients with symptom-producing lesions improve with resection.

Early trigeminal nerve involvement in Listeria monocytogenes rhombencephalitis: case series and systematic review.

Listeria monocytogenes is associated with rhombencephalitis. However, the exact mechanisms of brainstem invasion remains poorly understood. Here, we demonstrate clinical and radiological data suggesting that Listeria may invade the brainstem via the trigeminal nerve. Three females (41, 64 and 70years) with culture proven L. monocytogenes bacteremia and rhombencephalitis were investigated in the period of 2014-16. T2-weighted and contrast-enhanced T1-weighted MRI revealed a cerebellopontine abscess in all three patients, including the involvement of the trigeminal nerve root. In two patients, MRI also revealed selective contrast enhancement of the sensory trigeminal tract in the pons and medulla oblongata. Prior to any other neurological symptoms, two patients complained of hypoesthesia and a tingling sensation in the ipsilateral half of the face, consistent with sensory trigeminal nerve dysfunction on that side. In addition, we identified another 120 cases of Listeria rhombencephalitis following a systematic review. Cranial nerves VII, V, IX, and X, respectively, medulla oblongata, cerebellum and pons, were the most frequently involved brain structures. The present clinical and radiological findings corroborate earlier data from animal experiments, indicating that L. monocytogenes may be capable of retrograde intra-axonal migration along the cranial nerves. We suggest that in a subset of patients with rhombencephalitis L. monocytogenes enters the cerebellopontine angle through the trigeminal nerve, invading the brainstem via the sensory trigeminal nuclei.

Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews

BackgroundClinical examination findings are used in primary care to give an initial diagnosis to patients with low back pain and related leg symptoms. The purpose of this study was to develop best evidence Clinical Diagnostic Rules (CDR] for the identification of the most common patho-anatomical disorders in the lumbar spine; i.e. intervertebral discs, sacroiliac joints, facet joints, bone, muscles, nerve roots, muscles, peripheral nerve tissue, and central nervous system sensitization.MethodsA sensitive electronic search strategy using MEDLINE, EMBASE and CINAHL databases was combined with hand searching and citation tracking to identify eligible studies. Criteria for inclusion were: persons with low back pain with or without related leg symptoms, history or physical examination findings suitable for use in primary care, comparison with acceptable reference standards, and statistical reporting permitting calculation of diagnostic value. Quality assessments were made independently by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies tool. Clinical examination findings that were investigated by at least two studies were included and results that met our predefined threshold of positive likelihood ratio ≥ 2 or negative likelihood ratio ≤ 0.5 were considered for the CDR.ResultsSixty-four studies satisfied our eligible criteria. We were able to construct promising CDRs for symptomatic intervertebral disc, sacroiliac joint, spondylolisthesis, disc herniation with nerve root involvement, and spinal stenosis. Single clinical test appear not to be as useful as clusters of tests that are more closely in line with clinical decision making.ConclusionsThis is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. In some diagnostic categories we have sufficient evidence to recommend a CDR. In others, we have only preliminary evidence that needs testing in future studies. Most findings were tested in secondary or tertiary care. Thus, the accuracy of the findings in a primary care setting has yet to be confirmed.

Diagnostic triage for low back pain: a practical approach for primary care.

Diagnostic triage is an essential guideline recommendation for low back pain (LBP), which is the most frequent musculoskeletal condition that general practitioners encounter in Australia. Clinical diagnosis of LBP - informed by a focused history and clinical examination - is the key initial step for GPs, and determines subsequent diagnostic workup and allied health and medical specialist referral. The goal of diagnostic triage of LBP is to exclude non-spinal causes and to allocate patients to one of three broad categories: specific spinal pathology (<1% of cases), radicular syndrome (∼ 5-10% of cases) or non-specific LBP (NSLBP), which represents 90-95% of cases and is diagnosed by exclusion of the first two categories. For specific spinal pathologies (eg, vertebral fracture, malignancy, infection, axial spondyloarthritis or cauda equina syndrome), a clinical assessment may reveal the key alerting features. For radicular syndrome, clinical features distinguish three subsets of nerve root involvement: radicular pain, radiculopathy and spinal stenosis. Differential diagnosis of back-related leg pain is complex and clinical manifestations are highly variable. However, distinctive clusters of characteristic history cues and positive clinical examination signs, particularly from neurological examination, guide differential diagnosis within this triage category. A diagnosis of NSLBP presumes exclusion of specific pathologies and nerve root involvement. A biopsychosocial model of care underpins NSLBP; this includes managing pain intensity and considering risk for disability, which directs matched pathways of care. Back pain is a symptom and not a diagnosis. Careful diagnostic differentiation is required and, in primary care, diagnostic triage of LBP is the anchor for a diagnosis.

Leg pain location and neurological signs relate to outcomes in primary care patients with low back pain

BackgroundLow back pain (LBP) patients with related leg pain and signs of nerve root involvement are considered to have a worse prognosis than patients with LBP alone. However, it is unclear whether leg pain location above or below the knee and the presence of neurological signs are important in primary care patients. The objectives of this study were to explore whether the four Quebec Task Force categories (QTFC) based on the location of pain and on neurological signs have different characteristics at the time of care seeking, whether these QTFC are associated with outcome, and if so whether there is an obvious ranking of the four QTFC on the severity of outcomes.MethodAdult patients seeking care for LBP in chiropractic or general practice were classified into the four QTFC based on self-reported information and clinical findings. Analyses were performed to test the associations between the QTFC and baseline characteristics as well as the outcomes global perceived effect and activity limitation after 2 weeks, 3 months, and 1 year and also 1-year trajectories of LBP intensity.ResultsThe study comprised 1271 patients; 947 from chiropractic practice and 324 from general practice. The QTFC at presentation were statistically significantly associated with most of the baseline characteristics, with activity limitation at all follow-up time points, with global perceived effect at 2 weeks but not 3 months and 1 year, and with trajectories of LBP. Severity of outcomes in the QTFC increased from LBP alone, across LBP with leg pain above the knee and below the knee to LBP with nerve root involvement. However, the variation within the categories was considerable.ConclusionThe QTFC identify different LBP subgroups at baseline and there is a consistent ranking of the four categories with respect to outcomes. The differences between outcomes appear to be large enough for the QTFC to be useful for clinicians in the communication with patients. However, due to variation of outcomes within each category individuals’ outcome cannot be precisely predicted from the QTFC alone. It warrants further investigation to find out if the QTFC can improve existing prediction tools and guide treatment decisions.

Validation of MRI and Surgical Decision Making to Predict a Complete Resection in Pelvic Exenteration for Recurrent Rectal Cancer.

The main predictor of long-term survival in patients with recurrent rectal cancer is surgical resection with a clear resection margin. MRI plays a role in patient selection and surgical planning. This study aimed to validate MRI in determining pelvic involvement by comparing MRI to histological outcomes, to assess the effect of MRI on surgical planning by comparing MRI findings with the surgical procedure, and to compare MRI anatomical involvement with resection outcome to assess if MRI can predict a clear resection margin. Retrospective study reviewing prepelvic exenteration MRI and correlating organ, involving an MRI with pathological involvement and surgical outcomes. Single quaternary referral center with a special interest in pelvic exenteration. The patients included 40 men and 22 women with median age of 60 years who had locally recurrent rectal cancer. The accuracy of MRI as measured using sensitivity and specificity by correlating MRI involvement with pathological involvement was the primary outcome measured. Recurrence in the anterior and central compartments was identified with accuracy on MRI and was likely to be associated with clear resection margins. MRI was less accurate at determining pelvic sidewall involvement. Lateral recurrence, high sacral, and nerve involvement were more likely to be associated with a positive resection margin. Sensitivity and specificity for pelvic sidewall structures was 46% and 91%. Involvement of nerve roots (60%-69%) and the upper sacrum (80%) on MRI was more likely to predict a positive resection margin than involvement of major pelvic viscera (22%). This study was limited by its retrospective nature. MRI findings can be used to help predict resection margin. Prospective work with MRI interpretation and close correlation and involvement by pathologists is needed to address imaging and surgical limitations at the pelvic sidewall and high posterior margin.

Lateral Supratrochanteric Approach to Sciatic and Femoral Nerve Blocks in Children: A Feasibility Study.

Background Sciatic and femoral nerve blocks (SNB and FNB) result in effective lower limb analgesia. Classical SNB and FNB require patient repositioning which can cause pain and discomfort. Alternative approaches to sciatic and femoral nerve blocks in supine patients can be useful. Materials and Methods Neurostimulator-guided SNB and FNB from the lateral supratrochanteric approach were performed. Local anesthetic spread in SNB and FNB after radiographic opacification was analyzed. Time and number of attempts to perform blocks, needle depth, and clinical efficacy were assessed. Results Mean needle passes number and procedure time for SNB were 2.5 ± 0.3 and 2.4 ± 0.2 min, respectively. Mean needle passes number and procedure time for FNB were 2.7 ± 0.27 and 2.59 ± 0.23 min, respectively. Mean skin to nerve distance was 9.1 ± 0.45 cm for SNB and 8.8 ± 0.5 cm for FNB. Radiographic opacification of SNB showed local anesthetic spread close to the sacrum and involvement of sacral plexus nerve roots. Spread of local anesthetic in FNB was typical. Intraoperative fentanyl administration was required in 2 patients (9.5%) with mean dose 1.8 ± 0.2 mcg/kg. Mean postoperative pain score was 0.34 ± 0.08 of 10. Conclusion The lateral supratrochanteric approach to SNB and FNB in children can be an effective lower limb analgesic technique in supine patients. The trial is registered with ISRCTN70969666.

Comparison of the Effects of Epidural Anesthesia and Local Anesthesia in Lumbar Transforaminal Endoscopic Surgery

Background: Percutaneous endoscopic lumbar discectomy (PELD) is a standard technique for the treatment of lumbar disc hernia. Thus far, most surgeons have recommended local anesthesia. However, in clinical practice, some patients experience pain and are unable to cooperate with the surgery during intervertebral foramen hemp expansion. The use of general anesthesia may create a greater risk of complications because of nerve root anomalies; thus, intraoperative neurophysiological monitoring should be utilized. Reports regarding the use of epidural anesthesia are few in comparison. Objective: To investigate the risks and contingency plans of epidural anesthesia in lumbar transforaminal endoscopic surgery. Study Design: A retrospective analysis of all lumbar transforaminal endoscopic surgeries performed from 2010 to 2014. Setting: Kanghua hospital. Methods: Patients treated with local and epidural anesthesia were divided into 2 groups. In local anesthesia group (A) and local anesthesia group (B), 0.5% lidocaine and 0.25% ropivacaine was administered, respectively. The incidences of complications, including urological complications, in each surgical group as well as Oswestry disability idex (ODI) improvement rates, postoperative patient satisfaction rates, and x-ray exposure times were assessed. Results: From 2010 to 2014, there were 286 cases of lumbar transforaminal endoscopic surgeries, 121 cases utilizing local anesthesia and 165 cases utilizing epidural anesthesia. In cases in which neurological complications occurred after surgery, 15 cases involved nerve root numbness, including one case of foot drop and 2 cases of cerebrospinal leakage in the local anesthesia group, which accounted for 12.4% of group A. However, in the epidural anesthesia group, which accounted for 9.70% of group B, there were 16 cases of nerve root numbness, including 2 cases of foot drop and 2 cases of cerebrospinal leakage. No significant difference was detected in the incidence of neurological complications between the 2 groups (P &gt; 0.05). The ODI improvement rates were 86.0% in the local anesthesia group and 85.4% in the epidural anesthesia group (P &gt; 0.05). The average x-ray exposure times were 14.7 seconds and 16 seconds in the local anesthesia group and epidural anesthesia group, respectively (P &gt; 0.05). The postoperative patient satisfaction rates were 73.6% and 91% in the local anesthesia group and epidural anesthesia group, respectively (P &lt; 0.001). Limitations: This was a single-blind study, and the complications observed were related to the learning curve; all these factors may lead to biases. Conclusions: Epidural anesthesia in transforaminal lumbar surgery is feasible and safe, and no significant difference in neurological complications was observed between the epidural anesthesia and the local anesthesia groups. However, for the patients concerned, the postoperative patient satisfaction rate was significantly greater in the epidural anesthesia group. It is noteworthy that the x-ray exposure times of the groups were not significantly different. Key words: Epidural anesthesia, transforaminal lumbar surgery, neurological complications, cerebrospinal leak

How to Identify Back Pain With Nerve Root Involvement

How to Identify Back Pain With Nerve Root Involvement

Diagnosis of nerve root involvement in primary care consulters with low back-related leg pain

Diagnosis of nerve root involvement in primary care consulters with low back-related leg pain

The pain drawing as an instrument for identifying cervical spine nerve involvement in chronic whiplash-associated disorders.

ObjectiveThe aim of the study was to investigate the psychometric properties of a standardized assessment of pain drawing with regard to clinical signs of cervical spine nerve root involvement.DesignThis cross-sectional study included data collected in a randomized controlled study. Patients: Two hundred and sixteen patients with chronic (≥6 months) whiplash-associated disorders, grade 2 or 3, were included in this study.MethodsThe validity, sensitivity, and specificity of a standardized pain drawing assessment for determining nerve root involvement were analyzed, compared to the clinical assessment. In addition, we analyzed the interrater reliability with 50 pain drawings.ResultsAgreement was poor between the standardized pain drawing assessment and the clinical assessment (kappa =0.11, 95% CI: −0.03 to 0.20). Sensitivity was high (93%), but specificity was low (19%). Interrater reliability was good (kappa =0.64, 95% CI: 0.53 to 0.76). Conclusion: The standardized pain drawing assessment of nerve root involvement in chronic whiplash-associated disorders was not in agreement with the clinical assessment. Further research is warranted to optimize the utilization of a pain/discomfort drawing as a supportive instrument for identifying nerve involvement in cervical spinal injuries.

Classification of patients with low back-related leg pain: a systematic review.

BackgroundThe identification of clinically relevant subgroups of low back pain (LBP) is considered the number one LBP research priority in primary care. One subgroup of LBP patients are those with back related leg pain. Leg pain frequently accompanies LBP and is associated with increased levels of disability and higher health costs than simple low back pain. Distinguishing between different types of low back-related leg pain (LBLP) is important for clinical management and research applications, but there is currently no clear agreement on how to define and identify LBLP due to nerve root involvement.The aim of this systematic review was to identify, describe and appraise papers that classify or subgroup populations with LBLP, and summarise how leg pain due to nerve root involvement is described and diagnosed in the various systems.MethodsThe search strategy involved nine electronic databases including Medline and Embase, reference lists of eligible studies and relevant reviews. Selected papers were appraised independently by two reviewers using a standardised scoring tool.ResultsOf 13,358 initial potential eligible citations, 50 relevant papers were identified that reported on 22 classification systems. Papers were grouped according to purpose and criteria of the classification systems. Five themes emerged: (i) clinical features (ii) pathoanatomy (iii) treatment-based approach (iv) screening tools and prediction rules and (v) pain mechanisms. Three of the twenty two systems focused specifically on LBLP populations.Systems that scored highest following quality appraisal were ones where authors generally included statistical methods to develop their classifications, and supporting work had been published on the systems’ validity, reliability and generalisability. There was lack of consistency in how LBLP due to nerve root involvement was described and diagnosed within the systems.ConclusionNumerous classification systems exist that include patients with leg pain, a minority of them focus specifically on distinguishing between different presentations of leg pain. Further work is needed to identify clinically meaningful subgroups of LBLP patients, ideally based on large primary care cohort populations and using recommended methods for classification system development.Electronic supplementary materialThe online version of this article (doi:10.1186/s12891-016-1074-z) contains supplementary material, which is available to authorized users.

Comparison of Maitland Thoracic Spine Manipulation Versus Maitland Cervical Spine Mobilization in Chronic Unilateral C6 – C7 Cervical Radiculopathy

Background: Radicular pains are very common in cervical region due to C6 – C7 nerve root involvement which results discomfort and restriction of mobility of upper and lower segments of cervical and thoracic spine. A lot of evidences about non-operative treatments have been derived for managing cervical radiculopathies with a little documentation of manual therapy. So, in this study, Maitland concept of manipulation and mobilization at two different regions of spine (thoracic and cervical) respectively, was used to see the change in pain reduction and restoration of normal functional abilities.Methodology: A study design of Comparative single blinded, randomized control clinical trials was used. 100 patients having chronic unilateral C6 – C7 cervical radiculopathy’s symptoms due to disc prolapsed, divided into two groups with simple random sampling as guided per-consolidated standards of reporting trials (CONSORT) guidelines were used. First group was managed with Maitland thoracic spine manipulation (MTSM), mechanical intermittent cervical traction (MICT) for 10 minutes and regime of strengthening exercises (SE) and second group was managed with Maitland cervical spine mobilization (MCSM), MICT and SE. The duration of treatment was four weeks at the rate of three times in one week. Two outcome measures numeric pain rating scale (NPRS) and Neck disability index (NDI) questionnaire were used for evaluation and investigation. Data was collected at start, after two and after four Weeks’s treatment. Independent T test with extension of Levene’s test was used with 0.05% level of confidence.Results: The calculated p value for NPRS and NDI for group A (MTSM) was P = 0.000which was less than 0.05 having validation of significant changes. So, we reject our Null hypothesis that MTSM is more effective than MCSM.Conclusion: The result shows that MTSM and MC-SM were effective techniques for pain reduction and functional abilities restoration. However, the subjects of first group with MTSM, MICT and SE presented better progress in reduction of neck ache and refining functional status during comparison.

241 Identification of Nerve Root Involvement in Primary Care Consulters with Low Back–Related Leg Pain: Diagnostic Classification Using Alternative Approaches

241 Identification of Nerve Root Involvement in Primary Care Consulters with Low Back–Related Leg Pain: Diagnostic Classification Using Alternative Approaches