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Objective: To determine if preoperative leg pain and low back pain severity affected postoperative outcome. Method: Prospectively collected Spine-Tango data was analysed for 995 consecutive patients who underwent a primary, single level, lumbar micro-decompression/microdiscectomy at a single tertiary spinal centre. Result: At 3 months, 72% of patients were satisfied with the outcome of surgery. Pre-operative low back pain was a significant predictor of poor outcome (P < 0.01). Conclusion: Our study has shown that patients with a low back pain VAS of 6 or more have a significantly greater chance of a poor outcome following primary lumbar microdecompressive/microdiscectomy surgery. [ABSTRACT FROM AUTHOR]

BACKGROUND: Thoracic and dorsal pain caused by osteoporotic vertebral compression fractures is very common in clinic. Conventional treatment methods include medicine, physiotherapy, calcium supplement and local nerve block. They all have certain therapeutic effects, but the pain recurs shortly after drug withdrawal. As a technique for treating this kind of pain, pulsed radio frequency has a remarkable short-term effect, but it lacks standardized treatment for osteoporosis, and its long-term effect is not good. OBJECTIVE: To investigate the therapeutic effect of pulsed radio frequency combined with guideline calcium supplement on thoracic spinal nerve root pain caused by osteoporotic vertebral compression fracture. METHODS: The 110 patients with osteoporotic vertebral compression fractures were randomly divided into two groups, with 55 cases in each group. Informed consent was obtained from patients of the two groups. This study was approved by the Hospital Ethics Committee. Pulsed radiofrequency group received pulsed radiofrequency treatment for vertebral compression fracture corresponding to dorsal root ganglion of spinal nerve. Nerve block group received nerve block treatment for corresponding dorsal root ganglion of spinal nerve. Both groups were treated with calcium carbonate D3, calcitonin and zoledronic acid for osteoporosis. Visual Analogue Scale and Oswestry Dysfunction Index results were compared between the two groups before and 1, 3, 6 and 12 months after treatment. The N-terminal propeptide of human procollagen type I and tartrate-resistant acid phosphatase isomer 5b levels were compared between the two groups. RESULTS AND CONCLUSION: (1) The Visual Analogue Scale score and Oswestry Dysfunction Index were significantly improved in both groups after 1,3, 6 and 12 months of treatment compared with those before treatment (P< 0.05). In 1 month after operation, there was no significant difference between the two groups (P > 0.05). In 3, 6 and 12 months after operation, the improvement of Visual Analogue Scale score and Oswestry Dysfunction Index in the pulsed radiofrequency group was better than that in the nerve block group (P < 0.05). (2) There was no significant difference in bone metabolism indexes N-terminal propeptide of human procollagen type I and tartrate-resistant acid phosphatase isomer 5b between the two groups at 1 month after operation and before operation (P > 0.05). N-terminal propeptide of human procollagen type I and tartrate-resistant acid phosphatase isomer 5b in the two groups were significantly improved at 3, 6 and 12 months after operation (P < 0.05). (3) Pulse radio frequency combined with guideline calcium supplement in the treatment of chest and back pain caused by osteoporotic vertebral compression fractures can not only noticeably reduce pain and improve the quality of life, but also fundamentally improve osteoporosis, with satisfactory short-term and long-term results. [ABSTRACT FROM AUTHOR]

Aim: The aim of the study is to evaluate the effect of adding hypertonic saline to conventional transforaminal epidural steroid injections (TFESIs) in the management of patients with lumbar disc herniation (LDH) with radicular pain. Material and Methods: The study included 57 patients with L4-L5 LDH treated with TFESI. The patients were divided into two groups: the hypertonic (n = 29) and conventional groups (n = 28). The conventional group was administered with triamcinolone, bupivacaine, and isotonic saline. Subsequently, the hypertonic group was administered with triamcinolone, bupivacaine, and 10% hypertonic saline. The patients were followed up using the numeric rating scale (NRS) and Oswestry disability index (ODI). Substantial and moderate responder ratios were achieved using NRS. Outcome measurements were performed at baseline, one, three, six, and nine months. Complications were recorded in both groups. Results: TFESI with or without adjuvant hypertonic saline was found to be effective by achieving a significant reduction in NRS and ODI scores during the overall follow-up period. Reduction of NRS scores at six- and nine-month follow-up and ODI scores at nine-month follow-up in the hypertonic group were significantly higher than those in the conventional group. Moreover, substantial response in the hypertonic group was significantly higher than that in the conventional group. Both groups had no complications. Conclusion: The administration of adjuvant 10% hypertonic saline to transforaminal injections enhances the treatment efficacy by increasing pain reduction and improving the quality of life in the late follow-up period. [ABSTRACT FROM AUTHOR]

Study Design: A controlled, randomized, animal study.Objective: The aim of this study was to investigate the role of src-family kinases/p38 pathway in a rat model of lumbar disc herniation (LDH).Summary Of Background Data: LDH always generates radicular pain, and the mechanism remains unclear. We have reported that spinal src-family kinases (SFKs) may be involved in the process, but the downstream mechanism needs further investigation.Methods: LDH was induced by implantation of autologous nucleus pulposus (NP), harvest from the tail, in lumbar 4/5 spinal nerve roots of rat. Von Frey filaments and radiant heat tests were performed to determine mechanical and thermal pain threshold respectively. Basso, Beattie, and Bresnahan (BBB) scale was assessed to test the locomotor function. The protein level of p-SFKs, t-SFKs, p-p38, t-p38 in spinal cord was examined by western blotting analysis. Cellular location of p-p38 was determined by immunochemistry staining. Spinal tumor necrosis factor-alpha (TNF-α), interleukin (IL)-1β, and IL-6 levels were detected by enzyme-linked immunosorbent assay (ELISA).Results: Rats with NP implantation showed persistent ipsilateral mechanical allodynia and thermal hyperalgesia, which manifested as obvious decrease of paw withdrawal threshold (PWT) and paw withdrawal latency (PWL). BBB scale indicated the locomotor function of hindpaws in rats with NP implantation kept intact. Western blotting and immunohistochemistry staining revealed that phosphorylated SFKs (p-SFKs) and phosphorylated p38 MAPK (p-p38) were sequentially upregulated in ipsilateral spinal dorsal horn, but not in contralateral side of rats with NP. Intrathecal delivery of SFKs inhibitor reduced spinal p-p38 expression. Both SFKs and p38 inhibitors alleviated pain behaviors in a dose-responsive manner without disturbing locomotor function and reduced spinal expression of TNF-α, IL-1β, and IL-6 in rats with NP.Conclusion: Spinal SFKs contribute to radicular pain by activation of p38 MAPK and increasing pro-inflammatory cytokines expression in rats with NP implantation. Targeting SFKs/p38 pathway may be helpful for alleviating radicular pain.Level Of Evidence: N/A. [ABSTRACT FROM AUTHOR]

Background Context: The need for advanced imaging before spinal intervention is an area of ongoing debate. Many studies have demonstrated the accuracy of magnetic resonance imaging (MRI) results in evaluating structural pathology in the lumbar spine, but few have addressed how frequently MRI findings change clinical management. A randomized controlled trial showed that viewing MRI results did not impact outcomes in patients with radiculopathy undergoing epidural steroid injection (ESI). The results suggested ESIs that correlated with both imaging and clinical findings experienced slightly more benefit than the blinded cohort, although statistically insignificantly.Purpose: Three related studies were conducted to (1) increase understanding of the opinions of interventional spine physicians regarding the utility of viewing imaging before injection and (2) evaluate the impact of viewing MRI results on injection planning (retrospective and prospective analyses).Study Design: Survey, prospective, and retrospective analysis.Patient Sample: Patients presenting to a university-based spine center for initial evaluation of back or leg pain who were candidates for spinal intervention.Outcome Measures: Self-reported measures from a clinical practice questionnaire distributed to interventional spine physicians to determine rates and rationale for utilization of MRI before spine injection, physiologic measures including MRI results, functional measures including physician decision-making regarding type and location of injection performed.Methods: This study was funded by the University of Colorado Health and Welfare Trust. A survey was sent to interventional spine physicians to assess their utilization of MRI results before spine procedures. A retrospective analysis of patients who were candidates for ESI was conducted to evaluate how initial injection plan compared with the postviewing of MRI results on injection performed. In a prospective analysis, injection plans pre- and post-MRI were compared among patients presenting for initial evaluation of low back or leg pain.Results: Survey responses showed that specialists order MRI studies to correlate with physical exam (91%) and to detect the presence of synovial cysts (68%), whereas tumor/infection (93%) was most likely to cause a change in their approach. In the retrospective review, the physician's planned approach before viewing the MRI was concordant with the actual procedure 49% of the time. A different type of procedure was performed in 15% of planned injections. In such cases, the initial treatment plan was altered (ie, same procedure at a different or additional level or side) in 35% of planned injections. In the prospective data collection, 43% of injections were different from the initial physician decision. The most common reasons for altering the injection was different level affected (36%), facet pathology (22%), and different nerve root affected (16%).Conclusions: In clinical practice, MRI before injection frequently changes management decisions in the planning and delivery of lumbar spine injections. [ABSTRACT FROM AUTHOR]

Lumbar radicular pain is one of the most commonly encountered clinical syndromes; however, its underlying mechanistic basis, and its relation to the natural history of the disease, are poorly understood. We revieved the available literature to explore the pathophysiology and natural history of lumbar radicular pain. Experimental observations have spawned distinctive, but not mutually exclusive, pathophysiologic descriptions of radicular pain. These mechanisms include mechanical compression and inflammatory processes. In most cases, a complex interplay between these mechanisms is required to sustain the pain. However, when the dorsal root ganglion is mechanically deformed, sustained discharges causing pain can be evoked, leading to pain based on a purely mechanical basis. However, in other instances, previous sensitization of the nerve root by inflammatory processes is required. An understanding of these processes and the natural history of the syndrome is important to developing therapeutic strategies. [ABSTRACT FROM AUTHOR]

Low back pain (LBP) is one of the most frequent patient complaints in primary care. Common LBP diagnoses include nonspecific LBP, radicular pain, lumbar-disk herniation, spinal infection, and ankylosing spondylitis. A thorough history and physical exam are imperative. LBP treatment is multifactorial and blends pharmacologic and nonpharmacologic approaches. [ABSTRACT FROM AUTHOR]

Purpose: Intraforaminal ligaments (IFL) in lumbar neural foramina (NF) and their relation to the lumbar spinal nerves (SN) are addressed.Method: Giemsa- and PAS-stained plastinated body slices of 15 lumbar spines were made and compared to MRI and CT data acquired of the same fresh specimens. We dissected one fixed lumbar spine to discuss our results with previous literature. Macroscopic pathophysiological changes and operational interventions at these lumbar spines were excluded.Results: In the NF, thin medial IFL touch the SN. As a second compartment, intermedial vertical IFL are seen. A third lateral horizontal compartment of IFL is formed by thick cranial and caudal ligaments. Ligaments of the second and third compartments have no direct contact with the SN. From medial to lateral, the IFL thicken. All compartments are 3D reconstructed. If compartments of the IFL have no direct contact with the SN seen in the slices, a connection was noticed after dissection.Conclusion: Manual dissection seems to be inappropriate for a detailed study of the IFL. The lateral and intermedial compartments being free of the SN may transmit power and protect the SN, while the thin medial IFL may lead the SN passing the NF under physiological conditions. We conclude from the close topographical relation that the IFL may be relevant in foraminal stenosis. Any herniation in the NF presses IFL to the SN. Therefore, we think the IFL themselves could cause neurogenic claudication in case of their non-physiological turnover. Visualisation of IFL seems to be possible by using MRI. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Background: Motion preserving anterior cervical disc arthroplasty (ACDA) in patients with cervical radiculopathy was introduced to prevent symptomatic adjacent disc degeneration as compared with anterior cervical discectomy and fusion (ACDF). Prior reports suggest that ACDF is not more effective than anterior cervical discectomy (ACD) alone for the treatment of cervical radiculopathy.Purpose: To evaluate whether patients with cervical radiculopathy due to a herniated disc benefit more from undergoing ACDA, ACDF, or ACD in terms of clinical outcome measured by the neck disability index (NDI).Study Design: Double-blinded randomized controlled trial.Methods: One hundred-nine patients with one level herniated disc were randomized to one of the following treatments: ACDA, ACDF with intervertebral cage, ACD without fusion. Clinical and radiological outcome was measured by NDI, Visual Analogue Scale (VAS) neck pain, VAS arm pain, SF36, EQ-5D, patients' self-reported perceived recovery, radiographic cervical curvature, and adjacent segment degeneration parameters at baseline and until two years after surgery. BBraun Medical paid €298.837 to cover the costs for research nurses.Results: The NDI declined from 41 to 47 points at baseline to 19 ± 15 in the ACD group, 19 ± 18 in the ACDF group, and 20 ± 22 in the ACDA group after surgery (p=.929). VAS arm and neck pain declined to half its baseline value and decreased below the critical value of 40 mm. Quality of life, measured by the EQ-5D, increased in all three groups. Adjacent segment degeneration parameters were comparable in all three groups as well. No statistical differences were demonstrated between the treatment groups.Conclusions: The hypothesis that ACDA would lead to superior clinical outcome in comparison to ACDF or ACD could not be confirmed during a 2-year follow-up time period. Single level ACD without implanting an intervertebral device may be a reasonable alternative to ACDF or ACDA. [ABSTRACT FROM AUTHOR]

Objective: The common causes of eosinophilic meningitis are Angiostrongylus cantonensis and Gnathostoma spinigerum. To differentiate both parasites can be performed by serology test. This study aimed to use clinical factors to differentiate cause of eosinophilic meningitis from A. cantonensis or G. spinigerum. Materials and Methods: The authors retrospectively reviewed clinical factors of eosinophilic meningitis patients who were tested for A. cantonensis and G. spinigerum serology test at Srinagarind Hospital, Khon Kaen University, Thailand. Clinical factors were compared by descriptive statistics. Results: There were 33 eosinophilic meningitis patients who were tested for both parasites by serology tests. Of those, 22 patients were positive for A. cantonensis, while 11 patients were positive for G. spinigerum. Patients with A. cantonensis had more headache and fever, while patients with G. spinigerum had more migratory swelling, radicular pain, and abnormal Babinski's sign. Regarding laboratory tests, peripheral eosinophilia, numbers of white blood cells in the cerebrospinal fluid, and numbers of eosinophils in the cerebrospinal fluid were not different between eosinophilic meningitis patients from A. cantonensis and G. spinigerum. Conclusion: Clinical factors may be used to differentiate both parasites as a cause of eosinophilic meningitis. [ABSTRACT FROM AUTHOR]

Highlights • Knock-down of sodium channel subunits Na V 1.6 and Na V β4 reduced pain behaviors in the DRG compression model of low back pain. • The knock-down also reduced sensory neuron hyperexcitability and spontaneous activity, primarily in A-type neurons. • The 2 isoforms play similar roles in two low back pain models, DRG compression and DRG inflammation. • A similar pro-inflammatory cytokine profile is induced by both models, which was not affected by Na V β4 knock-down. • Targeting the abnormal spontaneous activity mediated by Na V 1.6 and Na V β4 may have therapeutic value. Abstract Low back pain is a common cause of chronic pain and disability. It is modeled in rodents by chronically compressing the lumbar dorsal root ganglia (DRG) with small metal rods, resulting in ipsilateral mechanical and cold hypersensitivity, and hyperexcitability of sensory neurons. Sodium channels are implicated in this hyperexcitability, but the responsible isoforms are unknown. In this study, we used siRNA-mediated knockdown of the pore-forming Na V 1.6 and regulatory Na V β4 sodium channel isoforms that have been previously implicated in a different model of low back pain caused by locally inflaming the L5 DRG. Knockdown of either subunit markedly reduced spontaneous pain and mechanical and cold hypersensitivity induced by DRG compression, and reduced spontaneous activity and hyperexcitability of sensory neurons with action potentials <1.5 msec (predominately cells with myelinated axons, based on conduction velocities measured in a subset of cells) 4 days after DRG compression. These results were similar to those previously obtained in the DRG inflammation model and some neuropathic pain models, in which sensory neurons other than nociceptors seem to play key roles. The cytokine profiles induced by DRG compression and DRG inflammation were also very similar, with upregulation of several type 1 pro-inflammatory cytokines and downregulation of type 2 anti-inflammatory cytokines. Surprisingly, the cytokine profile was largely unaffected by Na V β4 knockdown in either model. The Na V 1.6 channel, and the Na V β4 subunit that can regulate Na V 1.6 to enhance repetitive firing, play key roles in both models of low back pain; targeting the abnormal spontaneous activity they generate may have therapeutic value. [ABSTRACT FROM AUTHOR]

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Background: Radicular pain, caused by a lesion or autologous nucleus pulposus (NP) implantation, is associated with alteration in gene expression of the pain-signaling pathways. lncRNAs have been shown to play critical roles in neuropathic pain. However, the mechanistic function of lncRNAs in lumbar disc herniation (LDH) remains largely unknown. Identifying different lncRNA expression under sham and NP-implantation conditions in the spinal cord is important for understanding the molecular mechanisms of radicular pain.  Methods: LDH was induced by implantation of autologous nucleus pulposus (NP), harvested from rat tail, in lumbar 5 and 6 spinal nerve roots. The mRNA and lncRNA microarray analyses demonstrated that the expression profiles of lncRNAs and mRNAs between the LDH and sham groups were markedly altered at 7 days post operation. The expression patterns of several mRNAs and lncRNAs were further proved by qPCR. Results: LDH produced persistent mechanical and thermal hyperalgesia. A total of 19 lncRNAs was differentially expressed (>1.5-folds), of which 13 was upregulated and 6 was downregulated. In addition, a total of 103 mRNAs was markedly altered (>1.5-folds), of which 40 was upregulated and 63 downregulated. Biological analyses of these mRNAs further demonstrated that the most significantly upregulated genes in LDH included chemotaxis, immune response, and positive regulation of inflammatory responses, which might be important mechanisms underlying radicular neuropathic pain. These 19 differentially expressed lncRNAs have overlapping mRNAs in the genome, which are related to glutamatergic synapse, cytokine-cytokine receptor interaction, and the oxytocin-signalling pathway. Conclusion: Our findings revealed the alteration of expression patterns of mRNAs and lncRNAs in the spinal cord of rats in a radicular pain model of LDH. These mRNAs and lncRNAs might be potential therapeutic targets for the treatment of radicular pain. [ABSTRACT FROM AUTHOR]

Introduction : Use of Selective Nerve Root Block (SNRB) in lumbar region to relieve radicular pain along the course of a particular nerve is being practiced in the recent past. We observed and tabulated therapeutic outcomes of this procedure in management of radiculopathy induced by a prolapsed disc affecting a particular lumbar nerve root. Methods : 40 patients with various grades of disc prolapse affecting a particular lumbar nerve root presenting with chronic radicular pain were identified irrespective of age and sex. All were injected with a combination of 40 mg of Methylprednisolone based suspension with local anaesthetic over the affected nerve root and results were analyzed. Results : Those graded mild had 4.3 months relief and those graded moderate had 2.5 months relief. Those with severe disc prolapse had no relief except for the immediate postprocedural relief. Only 20% patients had relief up to 6 months. Conclusion : Effect of SNRB is typically short acting in majority of patients and recurrence is expected. It creates a window period with reduced pain but of varied intervals depending on the pathology. It did not alter the prognosis in those with severe disease where surgery is well indicated. Level of Evidence – Level 4.

Study DesignCase-control design.PurposeTo evaluate the role of the self-administered, self-reported history questionnaire (SSHQ) in identifying types of lumbar spinal stenosis (LSS).Overview of LiteratureDiagnosis of types of LSS is controversial.MethodsA total of 235 patients with LSS were asked to respond to the SSHQ. All of these patients recovered following surgical treatment. The classification of LSS patients was based on history, physical examinations, and imaging studies. It is considered to be the gold standard. Radicular and neurogenic claudication types of LSS were based on the SSHQ developed by Konno et al. Two categories of LSS were determined based on the SSHQ tool and gold standard. Finally, a sensitivity analysis was carried out to evaluate the diagnostic value of the SSHQ.ResultsThe mean age of patients was 59.4 years. According to the criteria for gold standard, patients were diagnosed with the radicular type (n=103), and neurogenic claudication type (n=132). The questionnaire had desirable sensitivity, specificity, and accuracy in categorizing the two types of LSS: 97.8%, 66.6%, and 96.8% for the radicular type, and 97.0%, 80.0%, and 95.7% for the neurogenic claudication type.ConclusionsOur findings indicate that the SSHQ is a reliable and a valid measure and it may be a clinical diagnosis support tool for identifying patients with two types of LSS.

Neuroinflammation induced by protruded nucleus pulposus (NP) has been shown to play a significant role in facilitation of radicular pain. Resolvin D2 (RvD2), a novel member of resolvin family, exhibits potent anti-inflammatory, pro-resolving and antinociceptive effects. But the effect of RvD2 in radicular pain remains unknown. The radicular pain rat models were induced by application of NP to L5 dorsal root ganglion. Each animal received intrathecal injections of vehicle or RvD2 (10 ng µl−1 or 100 ng µl−1). Mechanical thresholds were determined by measuring the paw withdrawal threshold for 7 days. The expressions of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) and transforming growth factor-β1 (TGF-β1) in ipsilateral lumbar segment of rat spinal dorsal horns were measured by using ELISA and real time-PCR. Western blot was used to measure the expressions of phosphorylated Akt (p-Akt) and phosphorylated glycogen synthase kinase 3 beta (p-GSK-3β). The expressions and distributions of RvD2 receptor, G-protein-coupled receptor 18 (GPR18), were also explored in the spinal cord of rats by using double-label immunofluorescence. RvD2 treatment caused significant reductions in the intensity of mechanical hypersensitivity and spinal expressions of TNF-α and IL-6. Meanwhile, RvD2 increased the expressions of TGF-β1 and regulated Akt/GSK-3β signaling. Furthermore, immunofluorescence showed that GPR18 colocalized with neurons and astrocytes in spinal cord. The results suggested that RvD2 might attenuate mechanical allodynia via regulating the expressions of inflammatory mediators and activation of Akt/GSK-3β signal pathway. RvD2 might offer a hopeful method for radicular pain therapy. [ABSTRACT FROM AUTHOR]

Back pain is a top primary and urgent care complaint; radicular pain can be caused by herniation of the nucleus pulposus (intervertebral disc), spinal stenosis, or degenerative changes to the vertebrae. The focus of this clinical review will be the clinical approach and treatment of lumbar radicular pain, cervical radicular pain, and spinal stenosis. Usually localized through neurological history, exam, and imaging, specific signs and symptoms for lumbar radicular, spinal stenosis, and cervical radicular pain can help determine etiology. Once radicular back pain has been diagnosed, a multitude of treatment options are available from rest and physical therapy to medications, epidurals, and surgery. The most common and accepted are reviewed. With accurate diagnosis, safe and effective pain management can be employed to shorten radicular episodes and manage recurrent or chronic radicular syndromes. Using a step-wise approach from diagnosis to conservative therapy to potential surgery, radicular pain syndromes can improve or resolve, and patients may achieve a better functional status and quality of life. [ABSTRACT FROM AUTHOR]

Abstract Lumbar disc herniation is a common cause of radicular pain, but the mechanism remains ambiguous and the treatment stays unsatisfied. Many studies revealed a traditional Chinese medicine puerarin may moderate chronic pain from diabetes and nerve injury. Thus far, the role and mechanism of puerarin in radicular pain is still unknown. In this study, by using a rat model of lumbar disc herniation, which was induced by autologous nucleus pulposus (NP) implantation, the analgesic effect of puerarin on radicular pain was tested. Puerarin was delivered intraperitoneally form 1 h before surgery, and once daily for 7 days. The results demonstrated that NP implantation induced long-lasting pain, characterized by decrease of paw withdrawal threshold (PWT) and paw withdrawal latency (PWL) in ipsilateral hindpaws, as long as day 20 after surgery. Spinal phosphorylated extracellular signal-regulated kinase (p-ERK) was up-regulated from day 5 to day 20 after surgery in ipsilateral but not contralateral side, and p-ERK was mainly co-localized with microglia. Puerarin decreased p-ERK expression from day 7 to day 20 after surgery. Puerarin or ERK inhibitor PD98059 alleviated pain behaviors, decreased expression of microglia marker ionized calcium-binding adaptor molecule 1 (Iba-1) in rats with NP implantation. The results suggested puerarin may alleviate radicular pain by inhibiting ERK-dependent or accompanied spinal microglia activation. Highlights • Rats with NP implantation showed chronic mechanical and thermal pain behaviors. • Puerarin and PD98059 alleviated pain behaviors in rats with NP implantation. • Puerarin decreased spinal p-ERK expression in rats with NP implantation. • Puerarin reduced spinal microglia marker Iba-1 expression in rats with NP implantation. • ERK inhibitor PD98059 reduced Iba-1 expression in rats with NP implantation. [ABSTRACT FROM AUTHOR]

Spinal disk herniation can induce radicular pain through chemical irritation caused by proinflammatory and immune responses. Bone marrow mesenchymal stem cells (BMSCs) are a unique type of adult stem cell with the functions of suppressing inflammation and modulating immune responses. This study was undertaken to observe the effect of intrathecal BMSCs on the treatment of mechanical allodynia and the suppression of microglial activation in a rat noncompressive disk herniation model. The model was induced by the application of nucleus pulposus (NP) to the L5 dorsal root ganglion (DRG). The study found that the use of NP in the DRG can induce abnormal mechanical pain, increase the contents of the proinflammatory factors TNF-α and IL-1β, decrease the content of the anti-inflammatory cytokine TGF-β1 and activate microglia in the spinal dorsal horns (L5) (P < 0.05). BMSC administration could increase the mechanical withdrawal thresholds dramatically, decrease the contents of IL-1β and TNF-α, increase the content of TGF-β1 significantly (P < 0.05) and inhibit microglial activation in the bilateral spinal dorsal horn. Our results indicate that BMSC administration can reduce mechanical allodynia and downregulate the expression of proinflammatory cytokines by inhibiting microglial activation in the spinal dorsal horn in a rat noncompressive disk herniation model. [ABSTRACT FROM AUTHOR]

Introduction: Spinal stenosis causing lower back pain and radiculopathy and it is the most common cause of patient admission at Spine centre as compared to other spine pathologies. Most common complaint in the Spine outpatient department or hospital admissions Different modalities have been applied with time for its management. Among them Epidural steroid injection is also. Objectives: "To Compare three doses of epidural steroid injection with single dose of epidural steroid injection for Lumbar Radicular pain in spinal stenosis patients." Study Design: Prospective study. Setting: Ghurki Trust Teaching Hospital, Lahore, Pakistan. Period: Jan 2016 to Dec 2016. Materials and Methods: 95 patients with lumbar radicular pain due to spinal stenosis were randomly allocated into 2 groups. In Group A, 42 patients were given 120 mg of Depo-medrol (40 mg per day for 3 days) along with local anesthesia and in group B, 43 patients were given 40 mg of Depo-medrol with local anesthesia as a single dose. Both Group A and Group B were matched in terms of age and gender. On visual analogue scoring, pain was assessed after 2 weeks, 3 months and 6 months. Results: In Group A (3 doses of depomedrol) VAS improvement at 2 weeks, 3 months and 6 months were more than group B (single dose of depomedrol) which was statistically significant (p < 0.05). There were no major complications like epidural hematoma or abscess formation in both groups. The overall minor complications like flushing, transient hyperglycemia and headache due to CSF hypotension were more in Group A than Group B but statistics shows no significant difference. All the adverse events resolved within few days without any significant morbidity and subsequent hospitalizations. Conclusion: Epidural steroid injection is excellent modality in the treatment of lower back pain with radiculopathy. Moreover 3 doses have greater effect in relieving pain as compared to single dose. There is no increase risk of complications by increasing dose. [ABSTRACT FROM AUTHOR]

Objective Minimally invasive percutaneous spinal procedures are popular in trying to reduce spinal pain. The aim of this paper is to evaluate the safety of intervertebral disc chemonucleolysis and to report the effectiveness of a percutaneous, minimally invasive treatment for contained herniated intervertebral discs in the lumbar spine using the recently marketed radiopaque gelified ethanol. Methods Pain relief before and after the procedure was self-evaluated by each patient using a verbal numeric scale (VNS) ranging from 0 to 10. Patients were also scored prior to procedure and after chemonucleolysis during several follow-up periods using the Roland-Morris low back pain and disability questionnaire (RMQ). Follow-up periods were defined as 0–6, 6–12, 12–18, 18–24, and 24–30 months. Clinically significant functional improvement (CSFI) was defined as a decrease of five or more points on the RMQ scale and a decrease of at least 50% of pain intensity using VNS. Results Using the RMQ scale, CSFI was achieved in 20/29 patients in the first follow-up period, 20/27 patients in the second follow-up period, 9/12 patients in the third follow-up period, 8/9 patients in the fourth follow-up period, and 4/4 patients in the last follow-up period. Using the VNS rating, CSFI was accomplished in 19/29 patients in the first follow-up period, 19/27 patients in the second follow-up period, 9/12 patients in the third follow-up period, 8/9 patients in the fourth follow-up period, and 4/4 in the last follow-up period. Conclusions Intradiscal application of gelified ethanol may be effective in pain reduction using the VNS and Roland-Morris low back pain and disability questionnaire. The treatment is safe and easy to handle. [ABSTRACT FROM AUTHOR]

Background Context: Because imaging findings of lumbar spinal stenosis (LSS) may not be associated with symptoms, clinical classification criteria based on patient symptoms and physical examination findings are needed.Purpose: The objective of this study was to develop clinical classification criteria that identify patients with neurogenic claudication (NC) caused by LSS.Study Design: This study is a two-stage process that includes Phase 1, the Delphi process, and Phase 2, the cross-sectional study.Patient Sample: Outpatients were recruited from spine clinics in five countries.Outcome Measure: The outcome measure includes items from the patients' history and physical examination.Methods: In Phase 1, a list of potential predictors of NC caused by LSS was based on the available literature and was evaluated through a Delphi process involving 17 spine specialists (surgeons and non-surgeons) from eight countries. In Phase 2, 19 different clinical spine specialists from five countries identified patients they classified as having (1) NC caused by LSS, (2) radicular pain caused by lumbar disc herniation (LDH), or (3) non-specific low back pain (NSLBP) with radiating leg pain. The patients completed survey items and the specialists documented the examination signs. Coefficients from general estimating equation models were used to select predictors, to generate a clinical classification score, and to obtain a receiver operating characteristic curve. Conduction of the Delphi process, data management, and statistical analysis were partially supported by an unrestricted grant of less than 15,000 US dollars from Merck Sharp & Dohme. No fees were allocated to participating spine specialists.Results: Phase 1 generated a final list of 46 items related to LSS. In Phase 2, 209 patients with leg pain caused by LSS (n=63), LDH (n=89), or NSLBP (n=57) were included. Criteria that independently predicted NC (p<.05) were age over 60 years, positive 30-second extension test, negative straight leg test, pain in both legs, leg pain relieved by sitting, and leg pain decreased by leaning forward or flexing the spine. A classification score using a weighted set of these criteria was developed. The proposed N-CLASS score ranged from 0 to 19 and had an area under the curve of 0.92, and the cutoff (>10/19) to obtain a specificity of >90.0% resulted in a sensitivity of 82.0%.Conclusions: Clinical criteria independently associated with neurogenic claudication due to LSS were identified. The use of these symptom and physical variables as a classification score for clinical research could improve homogeneity among enrolled patients. [ABSTRACT FROM AUTHOR]

Background: The predictive value of short-term arm pain relief after ‘indirect’ cervical epidural steroid injection (ESI) for the 1-month treatment response has been previously demonstrated. It remained to be answered whether the long-term response could be estimated by the early post-interventional pain course as well.Methods: Prospective observational study, following a cohort of n = 45 patients for a period of 24 months after ‘indirect’ ESI for radiculopathy secondary to a single-level cervical disk herniation (CDH). Arm and neck pain on the visual analog scale (VAS), health-related quality of life with the Short Form-12 (SF-12), and functional outcome with the Neck Pain and Disability (NPAD) Scale were assessed. Any additional invasive treatment after a single injection (second injection or surgery) defined treatment outcome as ‘non-response’.Results: At 24 months, n = 30 (66.7%) patients were responders and n = 15 (33.3%) were non-responders. Non-responders exited the follow-up at 1 month (n = 10), at 3 months (n = 4), and at 6 months (n = 1). No patients were injected again or operated on between the 6- and 24-month follow-up. Patients with favorable treatment response at 24 months had significantly lower VAS arm pain (p < 0.05) than non-responders at days 6, 8-11, and at the 3-month follow-up. The previously defined cut-off of > 50% short term pain reduction was not a reliable predictor of the 24-month responder status. SF-12 and NPAD scores were better among treatment responders in the long term.Conclusions: Patients who require a second injection or surgery after ‘indirect’ cervical ESI for a symptomatic CDH do so within the first 6 months. Short-term pain relief cannot reliably predict the long-term outcome. [ABSTRACT FROM AUTHOR]

Radicular pain is a common cause of disability. Traditionally treatment has been either epidural steroid injection providing short-term relief or surgery with associated complications. Pulsed radiofrequency (PRF) applied to the dorsal root ganglion (DRG) is a minimally invasive day-care treatment, which is gaining significant clinical acceptance in a selective group of patients with pure radicular pain. Greater insights into the immunomodulatory effects of this procedure may help to further optimise its application and find alternative treatment options. We have examined it’s effect on lymphocyte frequencies and secreted inflammatory markers in the cerebrospinal fluid (CSF) and correlated this with clinical outcome to identify clinical markers of chronic radicular pain. Ten patients were recruited for the study. CSF lymphocyte frequencies and levels of cytokines, chemokines and growth factors were quantified using flow cytometry and enzyme-linked immunosorbent assay (ELISA), respectively. Clinical assessment utilised Brief Pain Inventory scores. Nine out of ten patients (90%) demonstrated significant reduction in pain severity (p = 0.0007) and pain interference scores (p = 0.0015) three months post-treatment. Our data revealed significant reductions in CD56 + , CD3 − , NK cell frequencies (p = 0.03) and IFN-γ levels (p = 0.03) in treatment responders, while CD8 + T cell frequencies (p = 0.02) and IL-6 levels were increased (p = 0.05). IL-17 inversely correlated with post-treatment pain severity score (p = 0.01) and pre and post-treatment pain interference scores (p = 0.03, p = 0.01). These results support the concept that chronic radicular pain is a centrally mediated neuroimmune phenomenon and the mechanism of action of DRG PRF treatment is immunomodulatory. [ABSTRACT FROM AUTHOR]

Background: Immune and inflammatory responses occurring in the spinal cord play a pivotal role in the progression of radicular pain caused by intervertebral disk herniation. Interleukin-33 (IL-33) orchestrates inflammatory responses in a wide range of inflammatory and autoimmune disorders of the nervous system. Thus, the purpose of this study is to investigate the expression of IL-33 and its receptor ST2 in the dorsal spinal cord and to elucidate whether the inhibition of spinal IL-33 expression significantly attenuates pain-related behaviors in rat models of noncompressive lumbar disc herniation.Methods: Lentiviral vectors encoding short hairpin RNAs that target IL-33 (LV-shIL-33) were constructed for gene silencing. Rat models of noncompressive lumber disk herniation were established, and the spines of rats were injected with LV-shIL-33 (5 or 10 μl) on the first day after the operation. Mechanical thresholds were evaluated during an observation period of 21 days. Moreover, the expression levels of spinal tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), interleukin-6 (IL-6), and cyclooxygenase 2 (COX-2) and the activation of the mitogen-activated protein kinases (MAPK) and nuclear factor-κB (NF-κB) pathways were evaluated to gain insight into the mechanisms related to the contribution of IL-33/ST2 signaling to radicular pain.Results: The application of nucleus pulposus (NP) to the dorsal root ganglion (DRG) induced an increase in IL-33 and ST2 expression in the spinal cord, mainly in the dorsal horn neurons, astrocytes, and oligodendrocytes. Spinally delivered LV-shIL-33 knocked down the expression of IL-33 and markedly attenuated mechanical allodynia. In addition, spinal administration of LV-shIL-33 reduced the overexpression of spinal IL-1β, TNF-α, and COX-2 and attenuated the activation of C-Jun N-terminal kinase (JNK), extracellular signal-regulated kinase (ERK), and NF-κB/p65 but not p38.Conclusions: This study indicates that spinal IL-33/ST2 signaling plays an important role in the development and progression of radicular pain in rat models of noncompressive lumber disk herniation. Thus, the inhibition of spinal IL-33 expression may provide a potential treatment to manage radicular pain caused by intervertebral disk herniation. [ABSTRACT FROM AUTHOR]

Osteoid osteomas of the spine are benign bone tumors typically presenting with progressive pain without neurological deficit. This report presents a case of an osteoid osteoma in the lumbar spine associated with radicular pain. The patient, a young male athlete, presented with severe chronic nightly left low-back pain radiated to the ipsilateral lower extremity who failed to respond to physical therapy and analgesic medications. Initial radiologic examination was reported as normal, but closer inspection of the T1- and T2-weighted magnetic resonance image as well as technetium-99m total body bone scan and a computed tomography scan revealed a bony lesion in the left transverse process of the L4 vertebra consistent with the diagnosis of osteoid osteoma. A selective L3 nerve root block provided significant relief. Surgical excision of the osteoid osteoma resolved the symptoms. This case emphasizes the importance of early suspicion and diagnostic interventions in the detection and treatment of osteoid osteoma. [ABSTRACT FROM AUTHOR]

Background: Epidural steroid injection is widely used to treat the short and long-term symptoms of low back and radicular pain. To the best of our knowledge, the influence of transforaminal epidural steroid injection (TFSI) combined with caudal epidural steroid injection (CESI) on pain intensity, patient satisfaction, and quality of life in lumbar radiculopathy has not been examined.Aim: To evaluate the short and long-term efficacy of TFSI, and TFSI combined with CESI (TFSI + CESI) in patients with lumbar radiculopathy.Materials and Methods: We retrospectively examined the records of 104 patients with lumbar radicular pain and L4/5 and/or L5/S1 intervertebral disc disease who underwent TFSI or TFSI + CESI. We compared the pain intensity using a Visual Numeric Scale (VNS), North American Spine Society (NASS) pain satisfaction index, and EuroQol five dimensions (EQ-5D) quality of life scores before intervention, and after 1, 6 and 12 months.Results: In the TFSI group, the mean pre-treatment VNS score was 9.2, which improved to 4.9 after 1 month and to 7.2 after 12 months. In the TFSI + CESI group, the mean pre-treatment VNS score was 9.4, which improved to 2.6 and 4.6 after 1 and 12 months, respectively. Improvement in the VNS scores was significantly higher in the TFSI + CESI group (P < 0.0001 for each). Mean EQ-5D quality of life index in the TFSI group improved from 0.59 in the pre-treatment phase to 0.76 after 12 months of intervention, while it improved from 0.62 in the pre-treatment phase to 0.84 at 12 months of intervention in the TFSI + CESI group. The EQ-5D scores were significantly better in the TFSI + CESI group at 1, 6, and 12 months after the procedure (P = 0.004, 0.036, and 0.042, for 1, 6, and 12 months, respectively). The NASS scores were significantly better in the TFSI + CESI group at 6 and 12 months after the intervention (P = 0.025 and 0.001 for 6 months and 12 months, respectively).Conclusion: In patients with lower lumbar radiculopathy, a combined TFSI + CESI technique offers superior short and long-term pain relief, quality of life, and long-term patient satisfaction, than when TFSI is performed alone. [ABSTRACT FROM AUTHOR]