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Pain Physician Oct 2022Epidural injections are among the most commonly performed procedures for managing low back and lower extremity pain. Pinto et al and Chou et al previously performed... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Epidural injections are among the most commonly performed procedures for managing low back and lower extremity pain. Pinto et al and Chou et al previously performed systematic reviews and meta-analyses, which, along with a recent update from Oliveira et al showing the lack of effectiveness of epidural steroid injections in managing lumbar disc herniation, spinal stenosis, and radiculopathy. In contrast to these papers, multiple other systematic reviews and meta-analyses have supported the effectiveness and use of epidural injections utilizing fluoroscopically guided techniques. A major flaw in the review can be related to attributing active-controlled trials to placebo-controlled trials. The assumption that local anesthetics do not provide sustained benefit, despite extensive evidence that local anesthetics provide long-term relief, similar to a combination of local anesthetic with steroids is flawed.
STUDY DESIGN
The Cochrane Review of randomized controlled trials (RCTs) of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy were reanalyzed using systematic methodology and meta-analysis.
OBJECTIVES
To re-evaluate Cochrane data on RCTs of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy utilizing qualitative and quantitative techniques with dual-arm and single-arm analysis.
METHODS
In this systematic review, we have used the same RCTs from the Cochrane Review of a minimum of 20% change in pain scale or significant pain relief of >= 50%. The outcome measures were pain relief and functional status improvement. Significant improvement was defined as 50% or greater pain relief and functional status improvement. Our review was performed utilizing the Cochrane Review methodologic quality assessment and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Evidence was summarized utilizing the principles of best evidence synthesis and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. Clinical relevance of the pragmatic nature of each study was assessed.
RESULTS
In evaluating the RCTs in the Cochrane Review, 10 trials were performed with fluoroscopic guidance. Utilizing conventional dual-arm and single-arm meta-analysis, the evidence is vastly different from the interpretation of the data within the Cochrane Review. The overall combined evidence is Level I, or strong evidence, at one and 3 months, and Level II, or moderate evidence, at 6 and 12 months.
LIMITATIONS
The limitation of this study is that only data contained in the Cochrane Review were analyzed.
CONCLUSION
A comparative systematic review and meta-analysis of the Cochrane Review of randomized controlled trials (RCTs) of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy yielded different results. This review, based on the evidence derived from placebo-controlled trials and active-controlled trials showed Level I, or strong evidence, at one and 3 months and Level II at 6 and 12 months. This review once again emphasizes the importance of the allocation of studies to placebo-control and active-control groups, utilizing standards of practice with inclusion of only the studies performed under fluoroscopic guidance.
Topics: Humans; Radiculopathy; Anesthetics, Local; Sciatica; Low Back Pain; Injections, Epidural; Steroids
PubMed: 36288577
DOI: No ID Found -
International Journal of General... 2022Calcium-pyrophosphate-dihydrate-disease (CPPD) is a crystal-induced arthropathy. The lumbar-spinal involvement is rare and often under-diagnosed. This study aimed to... (Review)
Review
BACKGROUND
Calcium-pyrophosphate-dihydrate-disease (CPPD) is a crystal-induced arthropathy. The lumbar-spinal involvement is rare and often under-diagnosed. This study aimed to report the case of a lumbar spine CPPD involvement and to perform a systematic review of clinical, imaging features of lumbar involvement in CPPD patients, and treatments that have been implemented.
METHODS
This systematic review was conducted in accordance with the Preferred-Reporting-Items-for-Systematic-Reviews and Meta-Analyses (PRISMA) guidelines.
RESULTS
One hundred and sixty-seven articles met the search criteria using electronic databases searches. We retained 28 articles (20 case reports, 2 case series, 1 family survey, 4 retrospective studies, and 1 prospective study) involving a total of 62 patients. The age ranged between 39 and 89 years old. Among patients with lumbar spine CPPD, 32 were women. The duration of symptoms varied between one day and 8 years. The affection has been discovered during back pain in most cases. In 5 studies, the diagnosis was made on histological specimens of patients operated on for another pathology. X-ray showed calcifications in 2 cases. CT-scan detected calcium deposit in 7 cases. MRI showed lesions going from the increased signal of the disk, to calcified or not-cystic lesion of the facet joints, an intramedullary mass mimicking a schwannoma. Histological examination established the diagnosis of CPPD in 21 patients in all studies. Medical treatment included NSAIDs, Colchicine, Interleukin-1-receptor-antagonist, and antibiotics. Surgery was performed on 13 patients and allowed to establish the histological diagnosis.
CONCLUSION
In the case of inflammatory back pain in elderly subjects, without an infectious gateway, diagnosis of CPPD should be considered, especially for patients with a history of spinal surgery or degenerative radiography changes. CT scan is more sensitive than conventional radiographs. The discovertebral biopsy is the Gold-Standard and should be performed whenever the diagnosis was uncertain. Treatment includes the medical and surgical components.
PubMed: 36226310
DOI: 10.2147/IJGM.S360714 -
Global Spine Journal Apr 2023Systematic review and meta-analysis.OBJECTIVESSurgical decompression alone for patients with neurogenic leg pain in the setting of degenerative lumbar scoliosis (DLS)...
STUDY DESIGN
Systematic review and meta-analysis.OBJECTIVESSurgical decompression alone for patients with neurogenic leg pain in the setting of degenerative lumbar scoliosis (DLS) and stenosis is commonly performed, however, there is no summary of evidence for outcomes.
METHODS
A systematic search of English language medical literature databases was performed for studies describing outcomes of decompression alone in DLS, defined as Cobb angle >10˚, and 2-year minimum follow-up. Three outcomes were examined: 1) Cobb angle progression, 2) reoperation rate, and 3) ODI and overall satisfaction. Data were pooled and weighted averages were calculated to summarize available evidence.
RESULTS
Across 15 studies included in the final analysis, 586 patients were examined. Average preoperative and postoperative Cobb angles were 17.6˚ (Range: 12.7 - 25˚) and 18.0 (range 14.1 - 25˚), respectively. Average change in Cobb angle was an increase of 1.8˚. Overall rate of reoperation ranged from 3 to 33% with an average of 9.7%. Average ODI before surgery, after surgery, and change in scores were 56.4%, 27.2%, and an improvement of 29% respectively. Average from 8 studies that reported patient satisfaction was 71.2%.
CONCLUSIONS
Current literature on decompression alone in the setting of DLS is sparse and is not high quality, limited to patients with small magnitude of lumbar coronal Cobb angle, and heterogenous in the type of procedure performed. Based on available evidence, select patients with DLS who undergo decompression alone had minimal progression of Cobb angle, relatively low reoperation rate, and favorable patient-reported outcomes.
PubMed: 36127159
DOI: 10.1177/21925682221127955 -
World Neurosurgery Nov 2022Phrenic nerve dysfunction has been associated with cervical neuroforaminal stenosis in limited case reports and case-controlled studies. It is unclear if magnetic... (Review)
Review
BACKGROUND
Phrenic nerve dysfunction has been associated with cervical neuroforaminal stenosis in limited case reports and case-controlled studies. It is unclear if magnetic resonance imaging of the cervical spine should be included in the workup of patients with pulmonary dysfunction. A systematic review of the current literature was conducted on the topic to provide an outline of the body of knowledge and some guidance for neurosurgeons that receive these patient referrals.
METHODS
A systematic literature review was conducted through the PubMed database to identify articles related to phrenic nerve dysfunction secondary to cervical stenosis.
RESULTS
A total of 12 case reports were found. The median subject age was 64 years, 11 were male. Presenting symptoms included shortness of breath (n = 9), radiculopathy (n = 7), myelopathy (n = 5), reduced pulmonary function (n = 6), weakness (n = 4), and neck pain (n = 5). Ten of these patients underwent surgical intervention, all having improvements in their pulmonary and neurological symptoms at follow-up ranging from 10 days to 2 years.
CONCLUSIONS
Cervical stenosis, resulting in neuroforaminal stenosis, may be related to phrenic nerve dysfunction in select patients with idiopathic diaphragmatic paralysis or pulmonary dysfunction. Surgical decompression improves pulmonary and neurological symptoms.
Topics: Humans; Male; Middle Aged; Female; Constriction, Pathologic; Phrenic Nerve; Spinal Cord Diseases; Cervical Vertebrae; Respiratory Paralysis
PubMed: 36089276
DOI: 10.1016/j.wneu.2022.09.009 -
Journal of Orthopaedic Surgery and... Aug 2022Posterior minimally invasive surgery has been increasingly used in in recent years for the clinical treatment of cervical spondylosis. However, this treatment remains...
BACKGROUND
Posterior minimally invasive surgery has been increasingly used in in recent years for the clinical treatment of cervical spondylosis. However, this treatment remains challenging and has not been comprehensively reported. The aim of this study was to provide a systematic review of posterior minimally invasive treatment for cervical spondylosis to demonstrate the clinical efficacy and safety of this procedure.
METHOD
We collected information from patients with myelopathy or radiculopathy cervical spondylosis who underwent posterior minimally invasive surgery and verified the clinical efficacy and safety of these surgeries with different measurement indicators from five electronic databases: the Nurick, visual analog scale score, Japanese Orthopaedic Association (JOA) score, Neck Disability Index (NDI), EuroQol Five Dimensions Questionnaire (EQ-5D) score, Short-Form Health Survey Physical Component Summary (SF12-PCS) questionnaire score, Short-Form Health Survey Mental Component Summary (SF12-MCS) questionnaire score, and the MOS item short form health survey (HF-36) score. The decompression effect, cervical spine stability, average surgery time, surgical blood loss volume, length of hospital stay, and related complications were included in the descriptive analysis. Reporting of this protocol followed the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines checklist.
RESULTS
We identified 14 observational studies of cervical spondylosis with 479 patients, mainly including 197 cases of myelopathy and 207 cases of radiculopathy. Channel and endoscopic techniques were used. This study was certified by PROSPERO: CRD42021290074. Significant improvements in the quantitative indicators (Neck-VAS in 9 studies, JOA in 7 studies, NDIs in 5 studies, Nurick, ARM-VAS, and EQ-5D in 2 studies each, and the SF12-PCS, SF12-MCS, and HF-36 in 1 study each) were observed between pre- and postoperation (P < 0.05), and satisfactory clinical significance was acquired in the descriptive indicators [average surgery time (94.56 ± 37.26 min), blood loss volume (68.78 ± 103.31 ml), average length of stay (2.39 ± 1.20 d), and cervical spine stability after surgery]. Additionally, we showed that there was a 4.9% postoperative complication rate and the types of complications that may occur.
CONCLUSION
Posterior minimally invasive surgery is an effective and safe method for the treatment of cervical spondylosis and is a recommended optional surgical procedure for single-segment myelopathy and radiculopathy.
Topics: Cervical Vertebrae; Decompression, Surgical; Humans; Minimally Invasive Surgical Procedures; Radiculopathy; Spinal Cord Diseases; Spondylosis; Treatment Outcome
PubMed: 35964065
DOI: 10.1186/s13018-022-03274-3 -
Frontiers in Public Health 2022Traditionally paired meta-analysis revealed inconsistencies in the safety and effectiveness of surgical interventions. We conducted a network meta-analysis to assess... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Traditionally paired meta-analysis revealed inconsistencies in the safety and effectiveness of surgical interventions. We conducted a network meta-analysis to assess various treatments' clinical efficacy and safety for pure cervical radiculopathy.
METHODS
The Embase, PubMed, and Cochrane Library databases were searched for randomized controlled trials (RCTs) comparing different treatment options for patients with pure cervical radiculopathy from inception until October 23, 2021. The primary outcomes were postoperative success rates, postoperative complication rates, and postoperative reoperation rates. The pooled data were subjected to a random-effects consistency model. The protocol was published in PROSPERO (CRD42021284819).
RESULTS
This study included 23 RCTs ( = 1,844) that evaluated various treatments for patients with pure cervical radiculopathy. There were no statistical differences between treatments in the consistency model in terms of major clinical effectiveness and safety outcomes. Postoperative success rates were higher for anterior cervical foraminotomy (ACF: probability 38%), posterior cervical foraminotomy (PCF: 24%), and anterior cervical discectomy with fusion and additional plating (ACDFP: 21%). Postoperative complication rates ranked from high to low as follows: cervical disc replacement (CDR: probability 32%), physiotherapy (25%), ACF (25%). Autologous bone graft (ABG) had better relief from arm pain (probability 71%) and neck disability (71%). Among the seven surgical interventions with a statistical difference, anterior cervical discectomy with allograft bone graft plus plating (ABGP) had the shortest surgery time.
CONCLUSIONS
According to current results, all surgical interventions can achieve satisfactory results, and there are no statistically significant differences. As a result, based on their strengths and patient-related factors, surgeons can exercise discretion in determining the appropriate surgical intervention for pure cervical radiculopathy. CRD42021284819.
Topics: Cervical Vertebrae; Humans; Postoperative Complications; Radiculopathy; Spinal Fusion; Treatment Outcome
PubMed: 35910906
DOI: 10.3389/fpubh.2022.892042 -
International Journal of Spine Surgery Jul 2022Minimally invasive surgery (MIS) has benefits over open surgery for lumbar decompression and/or fusion. Published literature on its cost-effectiveness vs open techniques...
BACKGROUND
Minimally invasive surgery (MIS) has benefits over open surgery for lumbar decompression and/or fusion. Published literature on its cost-effectiveness vs open techniques is mixed.
OBJECTIVE
Systematically review the cost-effectiveness of minimally invasive vs open lumbar spinal surgical decompression, fusion, or discectomy using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
METHODS
A systematic electronic search of databases (MEDLINE, Embase, and Cochrane Library) and a manual search from the cost-effectiveness analysis (CEA) database and National Health Service economic evaluation database was conducted. Studies that included adult populations undergoing surgery for degenerative changes in the lumbar spine (stenosis, radiculopathy, and spondylolisthesis) and reported outcomes of costing analysis, CEA, or incremental cost-effectiveness ratio were included.
RESULTS
A total of 17 studies were included. Three studies assessed outcomes of MIS vs open discectomy. All 3 reported statistically significant lower total costs in the MIS, compared with the open group, with similar reported gains in quality-adjusted life years (QALYs). Two studies reported cost differences in MIS vs open laminectomy, with significantly lower total costs attributed to the MIS group. Twelve studies reported findings on the relative direct costs of MIS vs open lumbar fusion. Among those, 3 of the 4 studies comparing single-level MIS-transforaminal lumbar interbody fusion (TLIF) and open TLIF reported lower total costs associated with MIS procedures. Six studies reported cost evaluation of single- and 2-level TLIF procedures. Lower total costs were found in the MIS group compared with the open fusion group in all studies except for the subgroup analysis of 2-level fusions in a single study. Three of these 6 studies reported cost-effectiveness (cost/QALY). MIS fusion was found to be more cost-effective than open fusion in all 3 studies.
CONCLUSION
The studies reviewed were of poor to moderate methodological quality. Generally, studies reported a reduced cost associated with MIS vs open surgery and suggested better cost-effectiveness, particularly in MIS vs open single- and 2-level TLIF procedure. Most studies had a high risk of bias. Therefore, this review was unable to conclusively recommend MIS over open surgery from a cost-effectiveness perspective.
CLINICAL RELEVANCE
The incidence of spinal decompressive and fusion surgey and financial constraints on healthcare services continue to increase. This study aims to identify the cost and clinical effectiveness of common approaches to spinal surgery.
LEVEL OF EVIDENCE
3a.
PubMed: 35835570
DOI: 10.14444/8297 -
Journal of Rehabilitation Medicine Aug 2022To update the systematic review from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration and to evaluate the effectiveness of multimodal...
Effectiveness of Multimodal Rehabilitation Interventions for Management of Cervical Radiculopathy in Adults: An Updated Systematic Review from the Ontario Protocol for Traffic Injury Management (Optima) Collaboration.
OBJECTIVE
To update the systematic review from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration and to evaluate the effectiveness of multimodal rehabilitation interventions for the management of adults with cervical radiculopathy.
STUDY DESIGN
Systematic review and best-evidence synthesis.
METHODS
Eligible studies (from January 2013 to June 2020) were critically appraised using the Scottish Intercollegiate Guidelines Network and Risk of Bias 2.0 criteria. The certainty of the evidence was assessed according to Grading of Recommendations Assessment, Development, and Evaluation.
RESULTS
Four RCTs were deemed acceptable and 1 RCT was considered low quality. In adults with recent-onset cervical radiculopathy, multimodal rehabilitation was associated with a trivial and nonclinically important reduction in neck pain compared with mechanical cervical traction; no differences in disability were reported (1 study, 360 participants, low certainty of the evidence). In adults with cervical radiculopathy of any duration, (i) multimodal rehabilitation may be more effective than prescribed physical activity and brief cognitive-behavioural approach; specifically, a small reduction in arm pain and in function was found (1 study, 144 participants, low certainty of the evidence); (ii) no difference in pain reduction was found between multimodal rehabilitation interventions compared with an epidural steroid injection (1 study, 169 participants, low certainty of the evidence); and (iii) compared with surgery combined with neck exercises, multimodal rehabilitation interventions lead to similar arm pain reduction and improvement in function (1 study, 68 participants, low certainty of the evidence).
CONCLUSION
The evidence suggests that some multimodal rehabilitation care may provide small and trivial reduction in neck pain or improvement in function to patients with cervical radiculopathy.
Topics: Adult; Exercise; Exercise Therapy; Humans; Neck Pain; Ontario; Radiculopathy
PubMed: 35797062
DOI: 10.2340/jrm.v54.2799 -
Journal of Bodywork and Movement... Jul 2022Little attention has been given to support the use of slider and tensioner neural mobilization (NM) techniques for upper quadrant pain (UQP). The purpose of this study...
BACKGROUND
Little attention has been given to support the use of slider and tensioner neural mobilization (NM) techniques for upper quadrant pain (UQP). The purpose of this study was to systematically review the effectiveness of these techniques in patients with UQP.
METHOD
The PubMed, Cochrane Library and EBSCOhost were searched without chronological restriction to identify randomized clinical trials (RCTs) that assessed pain changes following NM in the upper quadrant. Two researchers independently performed screening, full-text assessment, data extraction and risk of bias assessment of the studies.
RESULTS
A total of 974 articles were identified, of which 25 were included in this systematic review. The score for methodological quality of studies included was between 5 and 10 with a mean score of 7.96 points. Results demonstrated that slider and tensioner NM techniques are considered beneficial in pain reduction of UQP in certain musculoskeletal conditions including carpal tunnel syndrome and cervical radiculopathy. Regarding other conditions such as subacromial impingement syndrome, lateral elbow tendinopathy and cubital tunnel syndrome, due to conflicting findings, various methodological limitations and/or inadequate information, the available evidence remains uncertain. Furthermore, slider NM was found to be more effective in acute conditions compared to tensioner NM that seems to provide further analgesic effect in chronic UQP.
CONCLUSIONS
This systematic review revealed that NM slider and tensioner techniques can be used as analgesic modalities for managing UQP resulting from cervical radiculopathy and carpal tunnel. There remain unanswered questions concerning other conditions, and, therefore, further well-designed RCTs are needed to examine the analgesic response of NM techniques in UQP.
Topics: Carpal Tunnel Syndrome; Chronic Pain; Humans; Musculoskeletal Diseases; Pain Management; Radiculopathy; Randomized Controlled Trials as Topic
PubMed: 35710209
DOI: 10.1016/j.jbmt.2022.03.002 -
The Bone & Joint Journal May 2022Cervical radiculopathy is a significant cause of pain and morbidity. For patients with severe and poorly controlled symptoms who may not be candidates for surgical...
AIMS
Cervical radiculopathy is a significant cause of pain and morbidity. For patients with severe and poorly controlled symptoms who may not be candidates for surgical management, treatment with transforaminal epidural steroid injections (CTFESI) has gained widespread acceptance. However, a paucity of high-quality evidence supporting their use balanced against perceived high risks of the procedure potentially undermines the confidence of clinicians who use the technique. We undertook a systematic review of the available literature regarding CTFESI to assess the clinical efficacy and complication rates of the procedure.
METHODS
OVID, MEDLINE, and Embase database searches were performed independently by two authors who subsequently completed title, abstract, and full-text screening for inclusion against set criteria. Clinical outcomes and complication data were extracted, and a narrative synthesis presented.
RESULTS
Six studies (three randomized controlled trials and three non-randomized observational studies; 443 patients) were included in the final review. The aggregate data support the efficacy of CTFESI in excess of the likely minimal clinically important difference. No major complications were described.
CONCLUSION
There is increasing evidence supporting the efficacy of CTFESI. Concerns regarding the occurrence of catastrophic complications, widely shared in the case report and anecdotal literature, were not found when reviewing the best available evidence. However, the strength of these findings remains limited by the lack of highly powered high-level studies and the heterogeneity of the studies available. Further high-quality studies are recommended to address the issues of efficacy and safety with CTFESI. Cite this article: 2022;104-B(5):567-574.
Topics: Humans; Injections, Epidural; Pain; Radiculopathy; Steroids; Treatment Outcome
PubMed: 35491579
DOI: 10.1302/0301-620X.104B5.BJJ-2021-1816.R1