The Dutch Multidisciplinary Occupational Health Guideline to Enhance Work Participation Among Low Back Pain and Lumbosacral Radicular Syndrome Patients

Purpose Based on current scientific evidence and best practice, the first Dutch multidisciplinary practice guideline for occupational health professionals was developed to stimulate prevention and enhance work participation in patients with low back pain (LBP) and lumbosacral radicular syndrome (LRS). Methods A multidisciplinary working group with health care professionals, a patient representative and researchers developed the recommendations after systematic review of evidence about (1) Risk factors, (2) Prevention, (3) Prognostic factors and (4) Interventions. Certainty of the evidence was rated with GRADE and the Evidence to Decision (EtD) framework was used to formulate recommendations. High or moderate certainty resulted in a recommendation “to advise”, low to very low in a recommendation “to consider”, unless other factors in the framework decided differently. Results An inventory of risk factors should be considered and an assessment of prognostic factors is advised. For prevention, physical exercises and education are advised, besides application of the evidence-based practical guidelines “lifting” and “whole body vibration”. The stepped-care approach to enhance work participation starts with the advice to stay active, facilitated by informing the worker, reducing workload, an action plan and a time-contingent increase of work participation for a defined amount of hours and tasks. If work participation has not improved within 6 weeks, additional treatments should be considered based on the present risk and prognostic factors: (1) physiotherapy or exercise therapy; (2) an intensive workplace-oriented program; or (3) cognitive behavioural therapy. After 12 weeks, multi-disciplinary (occupational) rehabilitation therapy need to be considered. Conclusions Based on systematic reviews and expert consensus, the good practice recommendations in this guideline focus on enhancing work participation among workers with LBP and LRS using a stepped-care approach to complement existing guidelines focusing on recovery and daily functioning.

Age-related characteristic of human intervertebral discs from normal anatomy’s point of view

Aim. To compare morphological characteristics between anterior and posterior parts of human intervertebral discs, taking into account age. Methods. Fragments of 36 intervertebral discs C5C6, D5D6, L5S1 anterior parts taken from deceased persons aged 34 to 94 years, median age 61.0 (50.5; 71.8) years were examined. The comparison group consists of histopathological material obtained from 12 patients with radicular syndrome during planned L5S1 microdiscectomies aged 3577 years, median age 48.5 (43.0; 58.8) years. There were no statistically significant differences in age between the studied groups (p=0.126023). All materials were divided into subgroups depending on the age of the deceased/operated: 3452 and 6094 years for material obtained from the deceased; 3551 and 5877 years for material obtained after surgery. The differences between the three groups were examined by the KruskalWallis test, and quantitative indicators in the two groups were compared by MannWhitney U-test. Results. In the anterior part of the intervertebral discs, signs of degenerative-dystrophic changes were noted in all studied samples. All samples of nucleus pulposus and annulus fibrosus were fibrocartilage with no inflammation. Statistically significant differences (р=0.0283) were obtained in the number of isogenous groups of chondrocytes in intervertebral discs C5C6 anterior part compared with D5D6, L5S1 in individuals aged 3452. Age subgroups (3452 and 6094 years old) differed significantly (р=0.0219) in the number of single chondrocytes according to results of morphometry of anterior part of intervertebral discs L5S1. Anterior and posterior parts of intervertebral discs L5S1 differed statistically significant in the number of isogenous groups of chondrocytes when comparing the subgroup of operated patients aged 3551 years (р=0.008475) with the subgroup of deceased persons aged 3452 years and the subgroup of operated patients aged 5877 years (р=0.033753) with the subgroup of deceased aged 6094 years. Conclusion. Anterior and posterior part of intervertebral discs L5S1 had similar qualitative histological characteristics; however, the number of isogenous groups of chondrocytes in the posterior part of intervertebral discs L5S1 samples indicated a greater effect of compression loading compared to anterior part of the same spinal motion segment.

Comparison of Pulsed Radiofrequency, Oxygen-Ozone Therapy and Epidural Steroid Injections for the Treatment of Chronic Unilateral Radicular Syndrome

Background and objectives: For the treatment of chronic unilateral radicular syndrome, there are various methods including three minimally invasive computed tomography (CT)-guided methods, namely, pulsed radiofrequency (PRF), transforaminal oxygen ozone therapy (TFOOT), and transforaminal epidural steroid injection (TFESI). Despite this, it is still unclear which of these methods is the best in terms of pain reduction and disability improvement. Therefore, the purpose of this study was to evaluate the short and long-term effectiveness of these methods by measuring pain relief using the visual analogue scale (VAS) and improvement in disability (per the Oswestry disability index (ODI)) in patients with chronic unilateral radicular syndrome at L5 or S1 that do not respond to conservative treatment. Materials and Methods: After screening 692 patients, we enrolled 178 subjects, each of whom underwent one of the above CT-guided procedures. The PRF settings were as follows: pulse width = 20 ms, f = 2 Hz, U = 45 V, Z ˂ 500 Ω, and interval = 2 × 120 s. For TFOOT, an injection of 4–5 mL of an O2-O3 mixture (24 μg/mL) was administered. For the TFESI, 1 mL of a corticosteroid (betamethasone dipropionate), 3 mL of an anaesthetic (bupivacaine hydrochloride), and a 0.5 mL mixture of a non-ionic contrast agent (Iomeron 300) were administered. Pain intensity was assessed with a questionnaire. Results: The data from 178 patients (PRF, n = 57; TFOOT, n = 69; TFESI, n = 52) who submitted correctly completed questionnaires in the third month of the follow-up period were used for statistical analysis. The median pre-treatment visual analogue scale (VAS) score in all groups was six points. Immediately after treatment, the largest decrease in the median VAS score was observed in the TFESI group, with a score of 3.5 points (a decrease of 41.7%). In the PRF and TFOOT groups, the median VAS score decreased to 4 and 5 points (decreases of 33% and 16.7%, respectively). The difference in the early (immediately after) post-treatment VAS score between the TFESI and TFOOT groups was statistically significant (p = 0.0152). At the third and sixth months after treatment, the median VAS score was five points in all groups, without a statistically significant difference (p > 0.05). Additionally, there were no significant differences in the Oswestry disability index (ODI) values among the groups at any of the follow-up visits. Finally, there were no significant effects of age or body mass index (BMI) on both treatment outcomes (maximum absolute value of Spearman’s rank correlation coefficient = 0.193). Conclusions: Although the three methods are equally efficient in reducing pain over the entire follow-up, we observed that TFESI (a corticosteroid with a local anaesthetic) proved to be the most effective method for early post-treatment pain relief.

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

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

Are general practitioners referring patients with low back pain for CTs appropriately according to the guidelines: a retrospective review of 3609 medical records in Newfoundland using routinely collected data

Background CT Imaging is often requested for patients with low back pain (LBP) by their general practitioners. It is currently unknown what reasons are common for these referrals and if CT images are ordered according to guidelines in one province in Canada, which has high rates of CT imaging. The objective of this study is to categorise lumbar spine CT referrals into serious spinal pathology, radicular syndrome, and non-specific LBP and evaluate the appropriateness of CT imaging referrals from general practitioners for patients with LBP. Methods A retrospective medical record review of electronic health records was performed in one health region in Newfoundland and Labrador, Canada. Inclusion criteria were lumbar spine CT referrals ordered by general practitioners for adults ≥18 years, and performed between January 1st-December 31st, 2016. Each CT referral was identified from linked databases (Meditech and PACS). To the study authors’ knowledge, guidelines regarding when to refer patients with low back pain for CT imaging had not been actively disseminated to general practitioners or implemented at clinics/hospitals during this time period. Data were manually extracted and categorised into three groups: red flag conditions (judged to be an appropriate referral), radicular syndrome (judged be unclear appropriateness), or nonspecific LBP (determined to be inappropriate). Results Three thousand six hundred nine lumbar spine CTs were included from 2016. The mean age of participants was 54.7 (SD 14 years), with females comprising 54.6% of referrals. 1.9% of lumbar CT referrals were missing/unclear, 6.5% of CTs were ordered on a red-flag suspicion, 75.6% for radicular syndromes, and 16.0% for non-specific LBP; only 6.5% of referrals were clearly appropriate. Key information including patient history and clinical exams performed at appointment were often missing from referrals. Conclusion This audit found high proportions of inappropriate or questionable referrals for lumbar spine CT and many were missing information needed to categorise. Further research to understand the drivers of inappropriate imaging and cost to the healthcare system would be beneficial.

Traction Therapy for Cervical Radicular Syndrome is Statistically Significant but not Clinically Relevant for Pain Relief. A Systematic Literature Review with Meta-Analysis and Trial Sequential Analysis

Aim: We aimed to investigate the effectiveness of traction therapy in reducing pain by performing a systematic review with meta-analysis. We also explore the best modality for administering traction to patients with cervical radicular syndrome (CRS). Methods: We searched the Medline, Physiotherapy Evidence Database (PEDro), Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) electronic databases. Two reviewers independently selected randomized controlled trials (RCTs) that compared traction in addition to other treatments versus the effectiveness of other treatments alone for pain outcome. We calculated the mean differences (MDs) and 95% confidence intervals (CIs). We used Cochrane’s tool to assess risk of bias and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to evaluate the quality of evidence and summarize the study conclusions. Results: A total of seven studies (589 patients), one with low risk of bias, were evaluated. An overall estimate of treatment modalities showed low evidence that adding traction to other treatments is statistically significant (MD −5.93 [95% CI, −11.81 to −0.04] P = 0.05 and I2 = 57%) compared to other treatments alone. The subgroup analyses were still statistically significant only for mechanical and continuous modalities. Conclusions: Overall analysis showed that, compared to controls, reduction in pain intensity after traction therapy was achieved in patients with cervical radiculopathy. However, the quality of evidence was generally low and none of these effects were clinically meaningful.