Factors predicting radical treatment after in-hospital conservative management of disk-related sciatica

doi:10.1016/S1297-319X(00)00237-2

Joint Bone Spine

Volume 68, Issue 1, February 2001, Pages 50-58

https://doi.org/10.1016/S1297-319X(00)00237-2 Get rights and content

Abstract

Objective. To determine predictive factors for radical treatment (nucleolysis or surgery) after in-hospital conservative management of low back pain with sciatica (LBPS). Patients and methods. A standardized form was used to collect data on 134 patients admitted for conservative treatment of LBPS. Subsequent radical procedures were recorded 11 to 24 months after discharge. Results. Forty-seven patients required radical treatment after discharge. Significant risk factors for radical treatment in the univariate analysis were taller stature, use of a lumbar support, more preadmission epidural injections, a positive straight leg-raising test, and a disk herniation diameter of at least 50% of the spinal canal diameter. Protective factors were onset within the month preceding admission and normal range of motion of the lumbar spine. In the multivariate analysis, symptom duration longer than one month, use of a lumbar support prior to admission, and a positive straight leg-raising test were associated with radical treatment. A positive straight leg-raising test was the only significant clinical risk factor in the subset of patients investigated by computed tomography (CT). When CT findings were added to the model, only size of the herniation was significant. Conclusion. Sixty-five percent of patients admitted for conservative treatment of LBPS do not receive radical treatment during a mean follow-up of 18 months. Several factors are associated with the likelihood of radical treatment.

Section snippets

Patients and methods

Between November 1, 1993, and December 31, 1994, 140 consecutive patients with disk-related LBPS were admitted to the rheumatology department of our teaching hospital for conservative treatment. The diagnosis of disk-related LBPS was established by one of us. All the patients met at least four of the six classification criteria of Saporta et al. [4] and/or had imaging study evidence of a disk herniation consistent with the clinical symptoms. Exclusion criteria were admission for nucleolysis,

Results

Table II, Table III and IV report the clinical and radiological findings in the 134 study patients. About one-fifth of the patients had no activities known to put strain on the low back, and about one-fifth had no history of disk disease. Seventy-six patients had had at least one prior episode of LBPS, twenty-five had a history of acute low back pain but no history of sciatica, and 17 had a history of chronic low back pain but no history of acute low back pain or sciatica (table I).

Eighty-seven

Discussion

Although none of the conservative treatments commonly used in LBPS have been validated, the treatment practices in our rheumatology department reflect those of French rheumatologists overall [6]. The goal of this study was not to evaluate the efficacy of our inpatient treatment protocol (bedrest, nonsteroidal anti-inflammatory drugs and, if needed, epidural glucocorticoid injections) but to look for factors that predict a need for radical treatment after discharge.

Among patients with LBPS,

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Cited by (16)

Similar outcome despite slight clinical differences between lumbar radiculopathy induced by lateral versus medial disc herniations in patients without previous foraminal stenosis: A prospective cohort study with 1-year follow-up
2014, Spine Journal
Citation Excerpt :
Although Ohmori et al. [17] also found no significant differences between the location of dorsal root ganglion and the preoperative sensory or motor disturbance and surgical outcomes, preoperative leg pain was higher (despite a lower limitation on the SLR) in their patients with extraforaminal location of dorsal root ganglion. Accordingly, to avoid self-prophecy effect leading to premature surgery, physicians should not be pessimistic when facing patients with lateral disc herniations but no spinal stenosis; moreover, as the angles of SLR are higher in those patients, lower angles of SLR was the only parameter predictive of further surgery as observed in nearly all prospective studies devoted to the outcome of patients with sciatica [18–20]. There are probably several explanations to the counterintuitive observation that patients with medial disc herniations have more restricted SLR than patients with lateral disc herniations.
It has been claimed that lumbar radiculopathy induced by foraminal disc herniations had poorer outcome and different clinical features, including: 1-more progressive onset, but shorter duration between the first sign and request of medical care; 2-more severe radiculopathy; 3-less frequent/severe back pain; 4-less limitation of straight leg raising (SLR); 5-more frequent neurologic deficiencies; 6-poorer outcome.
To check whether this still holds true when including only patients without other reasons for foraminal stenosis, that is, whether patients with medial disc herniations had different features and outcome than those with more lateral disc herniations.
All patients hospitalized to treat a lumbar radiculopathy within a 6-month period in two French rheumatology units in 2012 were included in this prospective study each time computed tomography scan or magnetic resonance imaging had already been performed and showed clear disc bulging/herniation but no features of medial or lateral spinal stenosis.
Fifty-nine patients (31 males, 49 with sciatica only) were included: 31 (53%) had medial disc herniations and 28 (47%) had more lateral herniations (posterolateral in 3, foraminal in 20, and far lateral in 5).
Outcome was assessed by a phone call 1 year after the baseline assessment using a standardized questionnaire. Patients were asked whether they experienced a relapse of their radiculopathy after discharge from the hospital; whether they had been operated or not; whether they felt it had improved or not; whether they felt cured or not; to assess their level of pain radiating in the leg when standing on a 0 to 10 verbal scale; and how long they could walk.
Features of patients with medial disc herniations were compared with patients with more lateral herniations.
No significant differences according to the location of herniations were noticed for the speed of radiculopathy onset, time elapsed since onset, back pain (both lying or standing), and leg pain (both lying or standing), but slight significant differences (t test<0.05) were observed for other items: the 28 patients with lateral herniations were 8 years older (53.4 ±15.8 vs. 45.2±12.6), their herniations involved discs from upper levels of the lumbar spine (above L4–L5: 7/28 vs. 3/31), motor weakness was more frequent (25% vs. 3%), SLR was less restricted (65.0°±24.5° vs. 51.1°±25.7°), DN4 score of neuropathic pain was higher (4.4±2.1 vs. 3.2±1.8), anxiety level was higher (10.3±4.1 vs. 7.9±3.2), length of hospital stay was longer (5.7±2.4 days vs. 4.5±1.4 days), and physician's prognosis of a good outcome was poorer (6.6±2.2 vs. 8.0±1.6). However, at the end of follow-up (12.2±3.3 months), outcome was similar: 37% (vs. 41% for medial herniations) had transiently relapsed, 66% felt finally improved (vs. 63%), and walking capacity was nearly identical despite the fact that only 18% had to be operated (vs. 32% of those with medial herniations).
Despite differences in clinical presentation, the outcome of radiculopathy induced by the more lateral lumbar disc herniations was not worse than the outcome of patients with only medial disc herniations. Previous claims of poorer outcome in foraminal herniations might be explained by the inclusion of patients with associated foraminal stenosis.
A single question was as predictive of outcome as the Tampa Scale for Kinesiophobia in people with sciatica: An observational study
2012, Journal of Physiotherapy
Citation Excerpt :
As physical therapy did influence global perceived effect at 1 year follow-up, the analyses were adjusted for treatment (Luijsterburg et al 2008). We also adjusted for gender (Jensen et al 2007, Peul et al 2008b, Skouen et al 1997, Weber 1978) and duration of symptoms at baseline (Carragee and Kim 1997, Tubach et al 2004, Valls et al 2001, Vroomen et al 2000, Vroomen et al 2002) because of their reported influence on outcome in patients with sciatica. To avoid problems due to multicollinearity we decided to perform three distinct regression analyses.
In people with sciatica in primary care, can a single question be used to predict outcome at 1 year followup as accurately as validated questionnaires on kinesiophobia, disability, and health-related quality of life?
Observational study within a randomised cohort.
135 people with sciatica in primary care.
Kinesiophobia was measured with the Tampa Scale for Kinesiophobia (TSK), disability with the Roland Morris Disability Questionnaire (RDQ), and health-related quality of life with the EQ-5D and the 36-item Short Form (SF-36) Physical Component Summary. Participants also answered a newly devised substitute question for each questionnaire on an 11-point numerical rating scale. Global perceived effect and severity of leg pain were recorded at 1 year follow-up.
The correlation coefficient between the TSK and its substitute question was r = 0.46 (p < 0.001). The substitute question was better at predicting pain severity in the leg at 1 year follow-up than the TSK (addition of explained variation of 11% versus 4% in a logistic regression analysis). The TSK and its substitute question did not significantly differ in their prediction of global perceived effect at 1 year follow-up. The other substitute questions and both the RDQ and EQ-5D did not contribute significantly to one or both of their prediction models.
It may be feasible to replace the TSK by a single substitute question for predicting outcome in people with sciatica in primary care. The other substitute questions did not consistently predict outcome at 1 year follow-up.
Pathophysiology of disk-related sciatica. I. - Evidence supporting a chemical component
2006, Joint Bone Spine
Citation Excerpt :
Large disk herniations may cause no symptoms [18–20], and on the other hand, some patients with severe symptoms have no evidence of nerve root compression upon imaging studies [21–23]. Furthermore, the severity of symptoms and neurological abnormalities is not well correlated with the size of the herniation [24–26]. Imaging features of the disk herniation have little prognostic value [27,28].
Sciatica in patients with disk disease was long ascribed to pressure put on the sciatic nerve root by a herniated disk. However, a role for chemical factors acting in conjunction with this mechanical insult is suggested by a number of clinical observations: disk surgery does not consistently provide pain relief, large disk herniations are not always symptomatic, severe pain may be present in patients without imaging evidence of nerve root compression, the severity of symptoms and neurological signs is not well correlated with the size of the disk herniation, and conservative therapy is often effective. Experimental studies have provided further evidence for a chemical component: disk herniations can undergo spontaneous resorption, the intervertebral disk is immunogenic, and mediators for inflammation have been identified within intervertebral disk tissue.
The current pathophysiological theory incriminates proinflammatory substances secreted by the nucleus pulposus (NP). When preexisting or concomitant mechanical injury to a nerve root occurs, these substances can cause nerve root pain. Animal experiments have established that the NP can induce functional and structural nerve root abnormalities in the absence of mechanical compression and that this effect is mediated by substances located at the surface of NP cells. Methylprednisolone, diclofenac, indomethacin, doxycycline, and cyclosporine induce variable inhibition of this effect. Available information points to tumor necrosis factor-α (TNF-α) as the main candidate among substances potentially responsible for nerve root pain. Therefore, trials of TNF-α antagonists in patients with disk-related sciatica are warranted.
Pathophysiology of disk-related sciatica. I. Evidence supporting a chemical component
2006, Revue du Rhumatisme (Edition Francaise)
Depuis la démonstration du lien entre hernie discale et sciatique, il était acquis que la compression radiculaire par une hernie discale était la cause de la sciatique, mais il est maintenant admis qu'à la composante mécanique s'associent des facteurs chimiques. Les arguments cliniques en faveur de la théorie « chimique » sont : les taux d'échecs de la chirurgie discale, l'existence de volumineuses hernies discales asymptomatiques, de radiculalgies sévères sans image de compression radiculaire, la corrélation médiocre entre la sévérité des symptômes et des signes neurologiques et la taille de la hernie discale, l'évolution souvent favorable après traitement conservateur. Les arguments expérimentaux plaident également en faveur de cette théorie : la capacité de résorption spontanée de la hernie discale, l'immunogénicité du disque intervertébral, la présence de médiateurs de l'inflammation au sein du disque. La théorie physiopathologique actuelle incrimine des substances pro-inflammatoires, secrétées par le nucleus pulposus (NP) qui, pour provoquer une radiculalgie, doivent être associées à une agression radiculaire mécanique préalable ou simultanée. Les expérimentations animales ont démontré que le NP pouvait, sans compression mécanique, induire des anomalies fonctionnelles et structurelles de la racine nerveuse, et que ces effets, plus ou moins inhibés par la méthylprednisolone, le diclofenac, l'indométhacine, la doxycycline et la cyclosporine, étaient générés par des substances situées à la surface des cellules du NP. À la lumière de ces données, il apparaît que le candidat expliquant le mieux ces phénomènes, est le tumor necrosis factor-α (TNF-α), justifiant ainsi l'essai des anti-TNF-α chez l'homme.
Factors predicting outcomes of mechanical sciatica. A review of 1092 cases
2004, Revue du Rhumatisme (Edition Francaise)
La sciatique commune constitue par sa fréquence et son retentissement socioprofessionnel un problème de santé publique.
Méthode. – À travers une étude rétrospective de 1092 cas de sciatique commune, nous précisons les caractéristiques épidémiologiques, cliniques, radiologiques et thérapeutiques et nous cherchons les facteurs associés à une mauvaise évolution afin de mieux apprécier le pronostic de cette affection.
Résultats. – L'âge moyen de nos patients est de 45,0 ± 13,3 ans avec une prédominance féminine (61,8 % des cas). Les antécédents de lombalgies sont notés dans 35,2 % des cas. La sciatique est mono-radiculaire dans 68 % des cas et touche essentiellement la racine L5. La cause de la sciatique est une hernie discale dans 58,4 % des cas. Le traitement médical initial est efficace dans 75 % des cas. À six mois, le résultat de tous les traitements confondus est satisfaisant dans 76,5 % des cas.
Conclusion. – Pour l'ensemble de la série, et en étude multivariée, les facteurs associés à une mauvaise évolution à six mois de recul sont : le travail de force (p = 0,049, Odds ratio (OR) = 1,69 ; IC = [1,01–2,86]) et l'obésité (p = 0,05, OR = 1,5 ; IC = [1,01–2,47]).
As an extremely common symptom and major source of lost productivity, mechanical sciatica places a heavy burden on public health.
Methods. – We retrospectively reviewed 1092 medical records to determine the epidemiological, clinical, imaging study, and therapeutic characteristics of mechanical sciatica. We also looked for factors associated with adverse outcomes.
Results. – Mean patient age was 45.0 ± 13.3 years, and 61.8% of patients were women. A history of low back pain was noted in 35.2% of cases. A single nerve root was involved in 68% of cases, and L5 was the most commonly affected root. Disk herniation was the cause in 58.4% of patients. First-line conservative treatment provided relief in 75% of cases, and the overall 6-month outcome was favorable in 76.5% of cases.
Conclusion. – The multivariate analysis conducted in the overall patient population showed that factors associated with adverse 6-month outcomes were heavy labor (odds ratio [OR], 1.69; 95% confidence interval [95% CI], 1.01–2.86; P = 0.049) and obesity (OR, 1.5; 95% CI, 1.01–2.47; P = 0.05).
Factors predicting outcomes of mechanical sciatica: A review of 1092 cases
2004, Joint Bone Spine
As an extremely common symptom and major source of lost productivity, mechanical sciatica places a heavy burden on public health.
Methods. – We retrospectively reviewed 1092 medical records to determine the epidemiological, clinical, imaging study, and therapeutic characteristics of mechanical sciatica. We also looked for factors associated with adverse outcomes.
Results. – Mean patient age was 45.0 ± 13.3 years, and 61.8% of patients were women. A history of low back pain was noted in 35.2% of cases. A single nerve root was involved in 68% of cases, and L5 was the most commonly affected root. Disk herniation was the cause in 58.4% of patients. First-line conservative treatment provided relief in 75% of cases, and the overall 6-month outcome was favorable in 76.5% of cases.
Conclusion. – The multivariate analysis conducted in the overall patient population showed that factors associated with adverse 6-month outcomes were heavy labor (odds ratio (OR) = 1.69; 95% confidence interval (95% CI) = 1.01–2.86; P = 0.049) and obesity (OR = 1.5; 95% CI = 1.01–2.47; P = 0.05).

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ORIGINAL ARTICLEFactors predicting radical treatment after in-hospital conservative management of disk-related sciatica

Abstract

Section snippets

Patients and methods

Results

Discussion

The natural history of herniated nucleus pulposus with radiculopathy

Spine

Nonoperative treatment of herniated lumbar intrevertebral disc with radiculopathy. An outcome study

Spine

Conférence de consensus sur l’imagerie de la sciatique vertébrale commune non opérée. Paris, 6–7 novembre 1990. Conclusions et recommandations du jury

Rachis

Résultats du traitement médical des sciatiques par hernie discale

Rev Rhum Mal Ostéoartic

Reasons for rheumatology department admission in 125 patients with disk-related sciatica

Rev Rhum [Engl Ed]

Inhospital management of common lumbosciatic syndrome. An opinion survey among French rheumatologists

Rev Rhum [Engl Ed]

Les sciatiques et autres affections basses en médecine libérale : ampleur du phénomène et attitudes thérapeutiques

Rev Epidemiol Santé Publique

Incidence and risk factors of herniated lumbar intervertebral disc or sciatica leading to hospitalization

J Chronic Dis

Infiltrations épidurales dans le traitement de la radiculopathie lombaire. À propos de 200 cas

Rev Chir Orthop

Lumbar disc herniation. Computed tomography scan changes after conservative treatment of nerve root compression

Spine

Traitement médical de la sciatique d’origine discale (nucléolyse exclue)

Résultats du traitement médical hospitalier de la sciatique discale : étude rétrospective dans 134 cas, avec un recul de 7 à 9 ans [abstract]

Rev Rhum Mal Ostéoartic

Lumbar disc herniation. A controlled, prospective study with ten years of observation

Spine

ORIGINAL ARTICLE
Factors predicting radical treatment after in-hospital conservative management of disk-related sciatica