Severe Sciatica Research Articles

CHARACTERISTICS OF SCIATICA PATIENTS LISTED FOR A SPINAL EPIDURAL STEROID INJECTION AND CLINICAL OUTCOMES: RESULTS FROM THE POISE COHORT STUDY

BackgroundClinical guidelines recommend epidural steroid injection (ESI) for severe sciatica but there is uncertainty of effectiveness. The POiSE study aims to identify factors, routinely collected in clinical practice that predict outcome in patients who have ESI. This presentation describes characteristics and early clinical outcomes of POiSE participants.MethodsProspective cohort study in 19 NHS spinal services in England, inviting patients with sciatica listed for an ESI. Participant baseline characteristics and 6-week follow-up outcomes are presented. Outcomes include pain intensity (0–10 NRS), disability (Oswestry Disability Index 0–100) and global change in symptoms.ResultsOver 24 months, 693 patients were invited to participate and 353 (51%) completed baseline questionnaires. Mean (SD) age 49.0 years (14.4), 60% female, and 46% (n=101) of those in work had certified time-off for sciatica. Mean pain intensity was 7.2 (2.0) and 6.2 (2.7) for leg and back pain respectively and mean disability (ODI) was 46.5 (18). 60% (n=210) had leg pain for >6 months. Average confidence at baseline (0 to 10) that the ESI would help symptoms was 5.7 (2.4).Of 217 patients reaching 6-week follow-up, mean leg and back pain intensity is 5.0 (2.8) and 4.9 (2.9) respectively and ODI 36.6 (20.4), with 57% reporting improvement (completely recovered/much better/better). Follow-up data collection at 6, 12 and 24-weeks post-ESI is ongoing.ConclusionInterim analysis shows only just over half of patients are reporting improvement at 6 weeks post ESI. The POiSE cohort study will help better identify the patients with sciatica who are most likely to benefit from this treatment.Conflicts of interestNoneSources of fundingThis study is supported by Health Education England and the National Institute for Health and Care Research (HEE/ NIHR ICA Programme Clinical Lectureship, Dr Siobhan Stynes, NIHR300441). The views expressed are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care

Predictors of outcome following an epidural steroid injection for disc-related sciatica: a Delphi consensus study

PurposeTrial data shows modest reductions in leg pain, disability and surgery avoidance following epidural steroid injections (ESI) for severe sciatica. Despite their common use, there is no clear evidence about which patients are more likely to benefit from ESI. The aim of this study was to generate consensus on potential predictors of outcome following ESI for disc-related sciatica.MethodsA list of potential predictors of outcome was generated during a consensus meeting of seven experts. The items were subsequently presented in a two round on-line Delphi study to generate consensus among experts on which items are potential predictors of outcome. Consensus was defined as 70% agreement among participants.ResultsSixty-one items were generated during the consensus meeting. Of ninety experts invited to participate in the on-line Delphi study, 44 (48%) and 33 (73%) took part in rounds one and two respectively. Twenty-eight additional items suggested by participants in round one were included in round two. Overall, 14 items reached consensus reflecting domains of health, medication use, pain intensity, psychosocial factors, imaging findings and type of injection.ConclusionBased on expert consensus, items that can be routinely collected in clinical practice were identified as potential predictors of outcomes following ESI.

Treatment strategy for osteoporotic vertebral body fractures in the lumbar spine: a case report and literature review

This report describes the successful treatment of an osteoporotic compression fracture. A 74-year-old woman presented with severe low back pain and left sciatica that had lasted for 6 weeks. Four week of conservative treatment was not effective. The patient was bedridden and had difficulty walking. A past history of osteoporosis was noted. Multilevel compression fractures, central stenosis, and spondylolisthesis with overt instability were evident in the preoperative images. Decompression and fusion surgery, vertebroplasty, and preoperative and postoperative teriparatide administration were planned. A severe endplate injury in the lower vertebral body was detected during interbody fusion surgery using an anterior approach. Additional screw insertion with posterolateral fusion was planned to prevent aggravation of cage subsidence. Postoperative magnetic resonance imaging, computed tomography (CT), and X-ray images revealed sufficient decompression, no cement leakage, and no nerve injury. On the first postoperative day, the patient reported that the left sciatica symptoms had improved. Satisfactory ambulation was observed at the outpatient department after 6 months. Fusion in progress was evident on follow-up CT and X-ray images. This case offers insights into possible treatment strategies for osteoporotic compression fractures with severe endplate injury, overt instability, and radiculopathy of the lower lumbar spine.

11 Years Old Female with Synergistic Presentation of Cranial and Spinal Pathologies: Myxopapillary Ependymoma with Hydrocephalus - A Rare Entity

The correlation between hydrocephalus and spinal cord tumor was first described by Kyrieleis et. al. 1% concomitant presence was documented by Mirroni et.al. Moreover, the understanding of the pathophysiological association between these two conditions is still lacking. 11 years old girl presented in the outpatient department of Jinnah hospital Lahore with complaints of difficulty in walking for the last 2 years, numbness of right leg for the last one year, and severe bilateral sciatica for 2 months. On further inquiry, she told that she is also suffering from headaches and blurred vision for the last 6 months. Her neuroimaging revealed hydrocephalus and mixed density heterogeneously enhancing intradural lesion at the conus. She underwent ventriculoperitoneal shunting for hydrocephalus and laminoplasty followed by excision of spinal tumor reported being myxopapillary ependymoma grade II. The presence of headache along with signs & symptoms of raised intracranial pressure in these patients warrant cranial imaging. CSF diversion for hydrocephalus and gross total excision of the spinal lesion is the standard acceptable treatment.

A case of severe sciatica caused by a lymphocele after renal transplantation

BackgroundSciatica is commonly caused by lumbar spinal disease. However, it can also be caused by tumors, infectious diseases, or muscle entrapment. We present a case of sciatica caused by a lymphocele after renal transplantation.PresentationA 50-year-old man who had undergone renal transplantation presented with sciatica and low back pain without leg edema. The patient was diagnosed with lumbar disc herniation during the first medical examination. Regardless of the treatment, the symptoms were exacerbated and red flag signs of low back pain were observed. Compression of the sciatic nerve by the lymphocele was confirmed by computed tomography. The sciatica was improved by ethanol injection for the lymphocele.ConclusionsWe encountered a rare case of severe sciatica without edema caused by lymphocele after renal transplantation. Careful examination is required to make a different diagnosis of lymphocele from other lumbar spinal diseases.

Only Surgical Decompression Is Sufficient for Multilevel Lumbar Spinal Stenosis with Calcified Disc Protrusion and Vacuum Disc: Case Reports

The purpose of this report was to share our successful cases of only surgical decompression for symptomatic multilevel lumbar spinal stenosis, by assessing treatment outcomes and perioperative complications. Two patients who had only surgical decompression for symptomatic multilevel lumbar spinal stenosis in March and May 2021 were investigated. They were preoperatively diagnosed with the calcified disc protrusion and vacuum disc in the intervertebral space by magnetic resonance imaging (MRI) and computed tomography (CT). The chief complaints were severe low back pain and bilateral sciatica 2 or 3 months ago. The patients reported also reported difficulty walking due to sciatica, for which they were admitted to Daegu Wooridul Spine Hospital. Under general anesthesia unilateral laminotomy for bilateral decompression (ULBD) was performed and discectomy was not done on the stenosis levels. Treatment outcomes were analyzed by preoperative and postoperative visual analog scale (VAS) for low back pain and sciatica (Back VAS and Leg VAS), improvement in walking, and postoperative MRI. Treatment outcomes were favorable: Low back pain and bilateral sciatica showed a VAS score improvement (Back VAS=3, Leg VAS=3), the patient’s walking was improved, and on a postoperative MRI of the two patients, the thecal sac was released sufficiently. The patients developed no perioperative complications. Only surgical decompression is an effective method for symptomatic multilevel lumbar spinal stenosis with calcified disc protrusion and vacuum disc in not the spinal canal but the intervertebral space.

Remodeling of the Lumbar Facet Joint After Full Endoscopic Resection for Lumbar Osteoid Osteoma: Case Report and Literature Review.

Osteoid osteoma (OO) is a common benign bone tumor; however, approximately 25% of cases have spine involvement. It is often treated by image-guided radiofrequency ablation to break down the nidus. Few reports have described full endoscopic resection of the lesion, but none have described postoperative remodeling of the lumbar facet joint after surgical resection of an OO. The study aimed to describe a rare case of remodeling of the lumbar facet joint and then delineate the least invasive surgical technique of endoscopic resection of an OO. A 26-year-old man presented with severe left buttock pain and sciatica that worsened at night and was relieved by ibuprofen. Magnetic resonance imaging indicated a left inferior facet of an L3 mass-like lesion. A thin-section computed tomography image revealed a nidus, which was compatible with an OO. Full endoscopic resection was performed to completely remove the nidus of the OO. At the 2-year follow-up, the patient was symptom-free and computed tomography images indicated new bone formation. The present case and literature review demonstrate that endoscopic resection is safe and effective for managing a posterior element of lumbar OO. Furthermore, this technique allows complete removal of the nidus with minimal damage to surrounding structures and leads to remodeling of the resection site. Patients with OO involving the posterior element of the spine can present with buttock and radicular pain, mimicking lumbar disc herniation. OO can be successfully removed by the full endoscopic method and remodeling of the resected site can be anticipated.

Application of Wearable Sensors Technology for Lumbar Spine Kinematic Measurements during Daily Activities following Microdiscectomy Due to Severe Sciatica.

Simple SummaryThe recurrence rate after lumbar spine disc surgeries is estimated to be 5–15%. Lumbar spine flexion of more than 10° is mentioned in the literature as the most harmful load to the operated disc level that could lead to recurrence during the first six postoperative weeks. The purpose of this study is to quantify flexions during daily living following such surgeries, for six weeks postoperatively, using wearable sensors technology. These data determine the patients’ kinematic pattern, reflecting a high-risk factor for pathology recurrence. The operated patients were measured to have 30% normal lumbar motion after the first postoperative week, while they were restored to almost 75% at the end of the sixth, respectively. Further in vitro studies should be carried out using these data to identify if such kinematic patterns could lead to pathology recurrence.Background: The recurrence rate of lumbar spine microdiscectomies (rLSMs) is estimated to be 5–15%. Lumbar spine flexion (LSF) of more than 10° is mentioned as the most harmful load to the intervertebral disc that could lead to recurrence during the first six postoperative weeks. The purpose of this study is to quantify LSFs, following LSM, at the period of six weeks postoperatively. Methods: LSFs were recorded during the daily activities of 69 subjects for 24 h twice per week, using Inertial Measurement Units (IMU). Results: The mean number of more than 10 degrees of LSFs per hour were: 41.3/h during the 1st postoperative week (P.W.) (29.9% healthy subjects-H.S.), 2nd P.W. 60.1/h (43.5% H.S.), 3rd P.W. 74.2/h (53.7% H.S.), 4th P.W. 82.9/h (60% H.S.), 5th P.W. 97.3/h (70.4% H.S.) and 6th P.W. 105.5/h (76.4% H.S.). Conclusions: LSFs constitute important risk factors for rLDH. Our study records the lumbar spine kinematic pattern of such patients for the first time during their daily activities. Patients’ data report less sagittal plane movements than healthy subjects. In vitro studies should be carried out, replicating our results to identify if such a kinematic pattern could cause rLDH. Furthermore, IMU biofeedback capabilities could protect patients from such harmful movements.

A novel technique for surgical excision of a symptomatic lumbar spine facet joint synovial cyst using a cyst dyeing method: a report of two cases and a literature review

The aim of this study was to investigate the efficacy of a cyst dyeing technique that was used during the surgical excision of facet joint cysts in 2 cases. We evaluated the patients’ clinical outcomes and perioperative complications after decompression of lumbar spinal stenosis caused by the cysts. Two patients, who underwent surgical decompression for symptomatic lumbar spinal stenosis caused by facet cysts in August and October 2020, were reviewed. Their main complaints were severe low back pain and sciatica 1 or 2 months ago, for which they visited Wooridul Spine Hospital, Daegu, Korea. Under general anesthesia, the cysts were removed with the cyst dyeing method, using indigo carmine. Clinical outcomes were assessed by preoperative and postoperative visual analog scale (VAS) scores. Perioperative complications were observed.Favorable clinical outcomes and no perioperative complications were reported. Low back pain and sciatica improved, as shown by changes of the VAS score from 9 or 8 to 1, and no dural defects were observed. The cyst dyeing method is an effective technique for the surgical removal of symptomatic lumbar spine facet joint cysts.

Minimally Invasive en bloc Excision of Rare Hemorrhagic Discal Cysts Using Unilateral Biportal Endoscopic Technique: A Report of Two Cases

Hemorrhagic discal cyst (HDC) in the lumbosacral spine is a rare cause for low back pain and radiculopathy. Although there is no treatment guideline in the literatures, it is believed that the surgical excision showed better treatment results than the conservative treatment. In this report, we have two excellent treatment results from two patients with HDC using the minimally invasive unilateral biportal endoscopic (UBE) technique. Two patients with the rare HDC in their lumbosacral spines came to our clinic due to low back pain and severe sciatica after failure of conservative treatment. Both patients’ MRI revealed a cystic mass mimic a ruptured lumbar disc herniation with compression of the nerve root. The cysts were excised using UBE technique. The features of UBE technique are two small surgical wounds, minimal muscle dissection, continuous normal saline irrigation, excellent hemostasis, and a crystal clear and magnified endoscopic surgical field. These features enable meticulous dissection, en bloc excision of the cyst, and reduce the risks of dural tears or nerve root injuries. Both patients had very good symptoms relief and quick recovery after the surgery with no complications. We believe that the UBE technique is a safe, effective, and excellent surgical treatment option for patients with HDC in the lumbosacral spine.

Minimally Invasive L5 Corpectomy with Navigated Expandable Vertebral Cage: A Technical Note.

Background: Conventional L5 corpectomy requires a large incision and an extended period of intraoperative fluoroscopy. We describe herein a new L5 corpectomy technique. Methods: A 79-year-old woman was referred to our hospital for leg pain and lower back pain due to an L5 vertebral fracture. Her daily life had been affected by severe lower back pain and sciatica for more than 2 months. We initially performed simple decompression surgery, but this proved effective for only 10 months. Results: For revision surgery, the patient underwent minimally invasive L5 corpectomy with a navigated expandable cage without fluoroscopy. The second surgery took 215 min, and estimated blood loss was 750 mL. The revision surgery proved successful, and the patient could then walk using a cane. In terms of clinical outcomes, the Oswestry Disability Index improved from 66% to 24%, and the visual analog scale score for lower back pain improved from 84 to 31 mm at the 1-year follow-up. Conclusions: Minimally invasive L5 corpectomy with a navigated expandable vertebral cage is effective for reducing cage misplacement and surgical invasiveness. With this new technique, surgeons and operating room staff can avoid the risk of adverse events due to intraoperative radiation exposure.

The relationship between pain and herniation radiology in giant lumbar disc herniation causing severe sciatica: 15 cases

Objective To evaluate conservative treatment of giant lumbar disc herniation in patients with extreme pain and to assess temporal changes in pain levels and radiological findings with short-term follow-up. Methods A total of 15 patients with severe pain (as measured by visual analog scale [VAS]) due to giant lumbar disc herniation and without neurological deficits were included. All patients received conservative treatment and were followed weekly for pain and medication assessment. MRI was performed at baseline, second month and fourth month to calculate disc herniation volume. The changes in disc herniation and pain were evaluated. Results There was no relationship between pain and the regression of disc herniation in these five females and ten males with a mean age of 41.4 years. MRI results showed an average of 20.3% and 20.4% regression of disc herniation from baseline to second month, and second month to fourth month, respectively. Whereas, pain levels had reduced from an average of 90.8–13.53 by the second month, and to 3.13 by the fourth month, indicating significant success with conservative treatment. Conclusions Regardless of the size of the herniation and the severity of the pain, patients with giant lumbar disc herniation should be encouraged to undergo conservative treatment, given that the patient does not have urinary-fecal incontinence, foot drop or progressive neurodeficit.

INNV-18. RECURRENT SHH MEDULLOBLASTOMA EXTRANEURAL METASTASES TO THE BONE MARROW WITHOUT CNS INVOLVEMENT

Abstract Medulloblastoma is the most common primary brain tumor in children, but is rare in adults. Because of the scarcity of adult medulloblastoma cases, treatment guidelines in the adult population are not well established, especially regarding surveillance and treatment of recurrent disease. A 47-year-old African American male presented with one month of progressive unsteady gait and dizziness. Imaging revealed a posterior fossa mass and the patient underwent gross total resection. Histology confirmed medulloblastoma and molecular subtyping revealed Sonic Hedgehog (Shh) pathway activation. No metastases were found at the time of diagnosis, and the patient received adjuvant craniospinal radiation therapy. Three years later the patient developed low back pain with severe sciatica affecting his gait and pancytopenia. Imaging revealed diffuse osseous disease without CNS recurrence and bone marrow biopsy confirmed recurrent medulloblastoma. The patient subsequently began reduced chemotherapy consisting of cisplatin and etoposide because of his severe pancytopenia. Due to a lack of response after 4 cycles, the SMO antagonist vismodegib was added. Follow-up imaging revealed improvement/stability of osseous disease, lab work demonstrated resolution of pancytopenia, and repeat bone marrow was without malignancy. Vismodegib was continued as maintenance therapy. Six months after completion of cisplatin/etoposide, follow-up imaging revealed progression of metastatic disease. Shh activated medulloblastomas have demonstrated responses to SMO inhibition. However, these responses are often transient secondary to rapid development of resistance, but may have a role to play in patients who have bone marrow involvement that limits use of cytotoxic therapy or bone marrow transplant. Due to poor survival outcomes associated with bone marrow metastases, aggressive screening for bone marrow metastases at diagnosis and in surveillance should be considered.

Spinal Emergency Surgery During Pregnancy: Contemporary Strategies and Outcome

Low back pain is a common complaint during pregnancy. However, spinal pathologies, which manifest with severe pain, radiculopathy, and acute neurologic deficits because of disk herniation or mass lesions require special attention. Here, we present our interdisciplinary experience in the surgical management of spinal emergencies during pregnancy. The data of pregnant women who underwent surgery for spinal pathologies over a 10-year period were collected. Patient-related characteristics such as maternal age, gestational age, preoperative workup, signs and symptoms of mothers, and diagnostic procedures were evaluated. After an interdisciplinary conference, individualized treatment plans regarding available options were developed. Fetal Doppler and cardiotocography were obtained before and after surgery. Nine pregnant women presented with spinal disorders and underwent spinal emergency surgery within the study period. The mean maternal age was 32.2 years. Six women presented with lumbar disk herniations manifesting as severe sciatica or foot drop and 3 patients had thoracic mass lesions resulting in cauda equine syndrome and/or ataxia. The mean gestational age at the time of presentation was 26.5 weeks. Caesarean sections were performed in 3 women prior to the neurosurgical procedure, whereas the pregnancies were maintained in the 6other patients. Eight infants who were healthy at birth had an unremarkable development. Surgery for spinal emergencies in pregnancy can be performed safely according to individual treatment plans developed by an interdisciplinary team taking into account the expectant mother's decision. Maintenance of pregnancy is possible and feasible in most patients.

Risk Factors for Neuropathic Pain in Middle-Aged and Elderly People: A Five-Year Longitudinal Cohort in the Yakumo Study.

To determine the risk factors for new neuropathic pain (NeP) after five years in healthy middle-aged and elderly volunteers. Prospective longitudinal cohort study (Yakumo study). Clinical evaluation in a health checkup. A total of 366 people (male N = 146, female N = 220, average age = 63.5 years) who did not have NeP in 2013 were examined. NeP was diagnosed based on a painDETECT questionnaire score ≥13. Body mass index (BMI), comorbidity, low back pain (LBP), sciatica, physical ability, grip and back muscle strength, osteoporosis, sarcopenia, frailty, spinal alignment, and quality of life (QOL) with the SF36 in 2013 were compared between NeP(+) and NeP(-) subjects in 2018 using multivariate logistic regression analysis. The NeP(+) rate in 2018 was 5.2%, with no significant differences in age and gender. NeP(+) subjects had significantly lower BMI, severe sciatica, poor gait ability, higher rates of osteoporosis and sarcopenia, greater lumbar kyphosis and spinal inclination, and poorer mental health in 2013. Poor gait ability (odds ratio [OR] = 8.05), low BMI (OR = 2.31), lumbar kyphosis (OR = 1.38), low percentage of the young adult mean (OR = 1.15), and low mental QOL (OR = 1.06) were identified as significant and independent risk factors for new NeP after five years. This longitudinal cohort study identified five independent risk factors for development of new NeP after five years, with related factors of spinal inclination, sarcopenia, and sciatica. New NeP may be prevented by intervention or treatment of these factors at an early stage in relatively healthy middle-aged and elderly people.

Predicting the outcome of persistent sciatica using conditioned pain modulation: 1-year results from a prospective cohort study.

Background and aims Recovery in patients hospitalised with severe sciatica is unpredictable. Prognostic tools to aid clinicians in the early identification of patients at risk of developing chronic sciatic pain are warranted. Conditioned pain modulation (CPM) is a psychophysical measure of the endogenous pain modulatory pathways. Several studies have suggested CPM as a potentially important predictive biomarker for the development of chronic pain. The aim of the study was to determine whether CPM effect in patients still suffering from leg pain 6 weeks after hospital discharge for severe sciatica is associated with persistent leg pain at 12 months. A potential association would suggest that measuring CPM effect could be a valuable prognostic tool in the hospital management of sciatica. Methods A prospective cohort study in which CPM effect was measured 6 weeks after hospital discharge following an acute admission with sciatica as the main complaint. The impact of CPM effect on the outcome was analysed using logistic regression. The outcome measured was self-reported leg pain score of ≥1 in the past week on a 0-10 numeric rating scale (NRS) at 12 months post discharge. Results A total of 111 patients completed the entire study, 51 of whom received non-randomised surgical treatment. Crude and confounder adjusted analyses showed no significant association between CPM effect and leg-pain measured at 12 months, crude Odds Ratio 0.87, 95% CI 0.7-1.1, p = 0.23. Conclusions Our results suggest that CPM assessment has limited prognostic value for the long-term outcome in severe sciatica when measured 6 weeks after hospital discharge. Implications The present study adds important knowledge concerning the limited clinical use of late CPM testing in sciatica patients. The heterogeneity in patients, the wide range of treatments received and a generally favourable outcome are factors that may affect CPM's clinical value as a prognostic factor for severe sciatica.

Modified three-stage Gaines procedure for symptomatic adult spondyloptosis

Spondyloptosis or complete anterior dislocation of the L5 vertebra over S1 is a rare clinical condition. In general, the surgical management of spondyloptosis includes either posterior long-segment in situ fusion (with total disregard for altered biomechanics) or restoration of lumbosacral kyphosis by reduction of spondyloptosis using multistaged procedures. Reduction is possible in spondyloptosis only after sacral dome osteotomy or L5 corpectomy with interbody fusion of L4 over S1 as described by Robert Gaines. We present the case of a 29 year old manual laborer who presented with complaints of severe low back pain and bilateral sciatica. He was diagnosed to have spondyloptosis of L5 over S1 with modified Newman's score of 10 + 10. The patient underwent three-staged modified Gaines procedure in the form of L5 corpectomy, reduction of L4 over S1 and interbody fusion between L4 and S1. The reduction was maintained at the end of 18 months and he was able to resume his job as a manual laborer.

Biographical suspension and liminality of Self in accounts of severe sciatica

Sciatica is a common form of low back pain (LBP) that has been identified as distinct both in terms of the persistence and severity of symptoms. Little research has explored individual experiences of sciatica, and none focuses on individuals with the most severe, long-lasting symptoms who may experience the most profound impact. This paper addresses this gap through proposing a theoretical framework for understanding such experiences, that of biographical suspension as a form of liminality of Self. Twenty semi-structured interviews were conducted with individuals with severe sciatic symptoms between January 2016‒March 2017, as part of the UK-based SCOPiC (SCiatica Outcomes in Primary Care) randomised controlled trial. Data were analysed thematically using the constant comparison method. The concept of ‘biographical suspension’, originally developed in LBP, emerged as one whereby individuals put life on-hold in the expectation of an eventual return to their former, pain-free selves. Deeper analysis extended this concept to a form of liminality, whereby individuals are caught between pre- and post-sickness selves, unable to fully identify with either. This liminality is underpinned by ongoing beliefs about sciatica as a temporary and fixable ‘injury’ rather than long-term ‘illness’, even among those with long-lasting symptoms. This led to a disjuncture between individuals' ongoing pain beliefs and experiences, resulting in longer-term psychological impacts. Biographical suspension is further conceptualised as an experiential stage giving rise to four distinct short-term trajectories: i) symptom resolution leading individuals to occupy a clearly post-liminal state; ii) remaining in suspended liminality; iii) ongoing symptoms leading to a post-liminal state of resignation; ix) a state of being both between sickness and wellness, and straddling hope and fear; thus exemplifying differing states of liminality experienced over time. Findings have implications for the support provided in clinical settings to individuals who may struggle to self-manage due to sustained liminality of Self.

Lessons learnt from a discontinued randomised controlled trial: adalimumab injection compared with placebo for patients receiving physiotherapy treatment for sciatica (Subcutaneous Injection of Adalimumab Trial compared with Control: SCIATiC)

BackgroundAdalimumab, a biological treatment targeting tumour necrosis factor α, might be useful in sciatica. This paper describes the challenges faced when developing a new treatment pathway for a randomised controlled trial of adalimumab for people with sciatica, as well as the reasons why the trial discussed was stopped early.MethodsA pragmatic, parallel group, randomised controlled trial with blinded (masked) participants, clinicians, outcome assessment and statistical analysis was conducted in six UK sites. Participants were identified and recruited from general practices, musculoskeletal services and outpatient physiotherapy clinics. They were adults with persistent symptoms of sciatica of 1 to 6 months’ duration with moderate to high level of disability. Eligibility was assessed by research physiotherapists according to clinical criteria, and participants were randomised to receive two doses of adalimumab (80 mg then 40 mg 2 weeks later) or saline placebo subcutaneous injections in the posterior lateral thigh. Both groups were referred for a course of physiotherapy. Outcomes were measured at baseline, 6-week, 6-month and 12-month follow-up. The main outcome measure was disability measured using the Oswestry Disability Index. The planned sample size was 332, with the first 50 in an internal pilot phase.ResultsThe internal pilot phase was discontinued after 10 months from opening owing to low recruitment (two of the six sites active, eight participants recruited). There were several challenges: contractual delays; one site did not complete contract negotiations, and two sites signed contracts shortly before trial closure; site withdrawal owing to patient safety concerns; difficulties obtaining excess treatment costs; and in the two sites that did recruit, recruitment was slower than planned because of operational issues and low uptake by potential participants.ConclusionsImproved patient care requires robust clinical research within contexts in which treatments can realistically be provided. Step changes in treatment, such as the introduction of biologic treatments for severe sciatica, raise complex issues that can delay trial initiation and retard recruitment. Additional preparatory work might be required before testing novel treatments. A randomised controlled trial of tumour necrosis factor-α blockade is still needed to determine its cost-effectiveness in severe sciatica.Trial registrationCurrent Controlled Trials, ISRCTN14569274. Registered on 15 December 2014.

Treatment of Sciatica Following Uterine Cancer with Acupuncture: A Case Report

For women, gynaecological or obstetrical disorders are second to disc prolapse as the most common cause of sciatica. As not many effective conventional treatments can be found for sciatica following uterine cancer, patients may seek assistance from complementary and alternative medicine. Here, we present a case of a woman with severe and chronic sciatica secondary to uterine cancer who experienced temporary relief from acupuncture.