Thermography: a call for scientific studies to establish its diagnostic efficacy

Thermography is reported to provide objective evidence of physiologic dysfunction in patients with low back pain and sciatica. This diagnostic test is appealing because it is painless, non-invasive, has no known adverse biologic effects, presents comprehensible graphic information, requires only a moderate investment in equipment, and should be an inexpensive procedure to perform. Unfortunately, the complete scientific information necessary to assess its diagnostic reliability is not available. This article discusses other experiments which have been performed to assess the diagnostic accuracy of tests for low back pain and sciatica and outline some features of an experimental protocol which would be essential to establish the reliability of thermography in the diagnosis of low back pain and sciatica due to herniated nucleus pulposus.     

Greater trochanter bursitis pain syndrome in females with chronic low back pain and sciatica

Trochanteric bursitis is a clinical condition which simulates major hip diseases and low back pain, it may also mimic nerve root pressure syndrome. Patients with greater trochanteric bursitis pain syndrome (GTBPS) usually suffer from pain radiating to the posterolateral aspect of the thigh, paraesthesiae in the legs, and tenderness over the iliotibial tract.. The purpose of this study is to indicate the similarity between the clinical features of the GTBPS and those of chronic low back pain, and to highlight the importance of diagnosing GTBPS in patients complaining of low back conditions. Three hundred female patients were included in this prospective study. All patients complained about chronic low back pain or sciatica and had a failed long term conservative treatment. Local injection of the tender peritrochanteric area was only done in half of the patients (group 1). Patients were required to answer the Oswestry Disability Index Questionnaire during all periods of follow-up. Patients of group 1 had a better clinical outcome (p < 0.0005) than the patients in group 2 where no injection was done. We conclude that greater trochanter bursitis pain syndrome is a frequent syndrome which may be associated with low back symptoms. Patients with a long standing history of low back pain and sciatica should be routinely checked for GTBPS. GTBPS is easy to diagnose and can be treated. Peritrochanteric infiltration with glucocorticoids mixed with 2% lidocaine relieves patients from their symptoms for a long period of time. Recurrence should always be expected, but treatment may be repeated.     

A prospective study of nerve root infiltration in the diagnosis of sciatica. A comparison with radiculography, computed tomography, and operative findings

Fifty nerve root infiltration studies were evaluated prospectively in a consecutive series of 50 patients referred to the Sheffield Problem Back Clinic with complicated back problems. All were over 35 years of age (mean, 51 years). Ten (20%) demonstrated abnormal segmentation of the lumbar spine. Sixteen (32%) had undergone previous surgery. Before nerve root infiltration all patients were investigated by radiculography and computed tomography. Nerve root infiltration identified two types of response. In 20 patients, infiltration reproduced the symptomatic pain, which then was abolished by local anesthetic--the positive result. These patients were considered suitable for surgery. One patient in this group had spontaneous resolution of pain and thus did not undergo operative treatment. In 30 patients, infiltration did not reproduce the symptomatic pain regardless of the level studied, or only partially reproduced the pain at two or more levels--the negative result. Radiculography and computed tomography in these patients also was inconsistent. This group were considered unsuitable for surgery. In those patients undergoing surgical decompression, nerve root infiltration correctly identified the symptomatic level in 18 of the 19. Computed tomography and radiculography identified the level in 14 and 12 patients, respectively.     

Diagnostic accuracy of history taking to assess lumbosacral nerve root compression

Background contextThe diagnosis of sciatica is primarily based on history and physical examination. Most physical tests used in isolation show poor diagnostic accuracy. Little is known about the diagnostic accuracy of history items.PurposeTo assess the diagnostic accuracy of history taking for the presence of lumbosacral nerve root compression or disc herniation on magnetic resonance imaging in patients with sciatica.Study designCross-sectional diagnostic study.Patient sampleA total of 395 adult patients with severe disabling radicular leg pain of 6 to 12 weeks duration were included.Outcome measuresLumbosacral nerve root compression and disc herniation on magnetic resonance imaging were independently assessed by two neuroradiologists and one neurosurgeon blinded to any clinical information.MethodsData were prospectively collected in nine hospitals. History was taken according to a standardized protocol. There were no study-specific conflicts of interest.ResultsExploring the diagnostic odds ratio of 20 history items revealed a significant contribution in diagnosing nerve root compression for “male sex,” “pain worse in leg than in back,” and “a non-sudden onset.” A significant contribution to the diagnosis of a herniated disc was found for “body mass index <30,” “a non-sudden onset,” and “sensory loss.” Multivariate logistic regression analysis of six history items pre-selected from the literature (age, gender, pain worse in leg than in back, sensory loss, muscle weakness, and more pain on coughing/sneezing/straining) revealed an area under the receiver operating characteristic curve of 0.65 (95% confidence interval, 0.58–0.71) for the model diagnosing nerve root compression and an area under the receiver operating characteristic curve of 0.66 (95% confidence interval, 0.58–0.74) for the model diagnosing disc herniation.ConclusionsA few history items used in isolation had significant diagnostic value and the diagnostic accuracy of a model with six pre-selected items was poor.     

Beyond the good prognosis. Examination of an inception cohort of patients with chronic low back pain

STUDY DESIGN: A 22-month prospective cohort study. OBJECTIVES: To describe the course of an inception cohort of patients with chronic low back pain. SUMMARY OF BACKGROUND DATA: Chronic low back pain is a debilitating condition with great medical and social cost. METHODS: A cohort of 1246 patients with acute low back pain who sought treatment from 208 North Carolina providers was observed. Patients who developed chronic low back pain were identified. Entry criteria were back pain of less than 10 weeks' duration, no previous care for this episode of low back pain, no previous spine surgery, not pregnant, no nonskin malignancy, and access to a telephone. The providers were of four types: primary care medical doctors, doctors of Chiropractic, orthopedic surgeons, and health maintenance organization-based primary care providers. Patients were contacted by telephone shortly after enrollment and at 2, 4, 8, 12, and 24 weeks, with a final interview at 22 months. Patient functional status, care-seeking, and satisfaction were evaluated. RESULTS: Ninety-six patients had chronic, continuous symptoms for 3 months, forming the inception cohort of chronic low back pain. A valid, reliable measure of back-specific functional disability also was used. Predictors of the development of chronicity were poor baseline functional status and sciatica. A more powerful predictor of chronicity was poor functional status at 4 weeks. Two thirds of patients with chronic low back pain at 3 months had functionally disabling symptoms at 22 months, and a majority of these were employed. Satisfaction with care was low. Forty-six patients (2.6% of the entire cohort) underwent surgery, with no statistically significant difference in surgical rates among initial provider strata. Patients who underwent surgery after 3 months had a Roland disability score at 22 months of 10 (7.7, 12.3). Forty-one percent of patients with chronic low back pain see an orthopedic or neurologic surgeon. Chronic low back pain occurs in 7.7% of patients who seek care for acute low back pain, with unremitting pain for 22 months in 4.7%. CONCLUSION: Once established, chronic low back pain is persistent. Most patients with chronic low back pain seek little care, and a majority are employed. Future research should emphasize maintenance of employment and function.     

The Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack) Study: baseline data.

STUDY DESIGN: Prospective cohort study of randomly selected Veterans Affairs (VA) outpatients. OBJECTIVE: To determine the prevalence of magnetic resonance imaging (MRI) findings in the lumbar spine among persons without current low back pain or sciatica and to examine which findings are related to age or previous back symptoms. SUMMARY OF BACKGROUND INFORMATION: Previous studies of patients without low back pain have not explored the possible association of various MRI findings to past symptoms. METHODS: We randomly selected an age-stratified sample of subjects without low back pain in the past 4 months from clinics at a VA hospital. We collected information on demographics, comorbidity, functional status, and quality of life. MR images were obtained using a standardized protocol through each of the five lumbar disc levels. RESULTS: Of 148 subjects, 69 (46%) had never experienced low back pain. There were 123 subjects (83%) with moderate to severe desiccation of one or more discs, 95 (64%) with one or more bulging discs, and 83 (56%) with loss of disc height. Forty-eight subjects (32%) had at least one disc protrusion and 9 (6%) had one or more disc extrusions. CONCLUSION: Many MR imaging findings have a high prevalence in subjects without low back pain. These findings are therefore of limited diagnostic use. The less common findings of moderate or severe central stenosis, root compression, and extrusions are likely to be diagnostically and clinically relevant.     

Pain and orthopaedic and neurologic signs after lumbar discectomy: a 2-year followup

In a prospective study of 161 consecutive patients with lumbar discectomy, pain, lumbar mobility, and neurologic and root tension signs were followed up for at least 2 years. Sciatica and root tension signs decreased promptly after surgery and remained largely unchanged during followup, which was not the case for neurologic signs. Similarly, pain relief was not associated with neurologic signs but was associated with lumbar mobility and root tension signs. Patients without neurologic symptoms before surgery did not report more sciatica after 2 years than did those with positive neurologic signs before surgery. Positive crossed Lasegue sign and restricted lumbar mobility before surgery predicted better chances for postoperative pain relief. Patients with a ruptured anulus fibrosus at surgery had less sciatica and back pain after surgery than did patients with an intact anulus fibrosus.     

Newest knowledge of low back pain. A critical look.

Scientific scrutiny of the low back problem demonstrates its socioeconomic importance in most industrialized societies. Natural history studies reveal that the prognosis for the low back pain patient is excellent; for those with sciatica and painful spondylolisthesis it is good. It is even relatively good for those older patients with symptoms of spinal stenosis. Although today there is a better understanding of pain, the pathomechanism of low back pain is unknown. However, for patients with sciatica, spondylolisthesis, and spinal stenosis, physicians are beginning to get a better perception of what causes the pain. Psychosocial factors, including insurance benefits, have been demonstrated to be more important than biomechanical workload not only for acute but also for chronic low back pain patients who are unable to work. Orthopedic surgeons must recognize this fact when contemplating operations for patients with ill-defined back syndromes. Rarely are diagnoses scientifically valid, nor is the effectiveness of surgery proven by acceptable clinical trials.     

Correlation of nerve root pain with dermatomal sensory threshold and back pain with spinal movement in single level lumbar spondylosis

We studied 27 patients with low back pain and unilateral L5 or S1 spinal nerve root pain. Significant radiological changes were restricted to the symptomatic root level, when compared with controls. Low back and leg pain were graded on a visual analogue scale. Dermatomal quantitative sensory tests revealed significant elevations of warm, cool and touch perception thresholds in the affected dermatome, compared with controls. These elevations correlated with root pain (warm v L5 root pain; r = 0.88, p < 0.0001), but not with back pain. Low back pain correlated with restriction of anteroposterior spinal flexion (p = 0.02), but not with leg pain. A subset of 16 patients underwent decompressive surgery with improvement of pain scores, sensory thresholds and spinal mobility. A further 14 patients with back pain, multilevel nerve root symptoms and radiological changes were also studied. The only correlation found was of low back pain with spinal movement (p < 0.002). We conclude that, in patients with single level disease, dermatomal sensory threshold elevation and restriction of spinal movement are independent correlates of sciatica and low back pain.     

Greater trochanteric pain syndrome in patients referred to orthopedic spine specialists.

BACKGROUND CONTEXT: Greater trochanteric pain syndrome (GTPS) is a regional syndrome characterized by pain and reproducible tenderness in the region of the greater trochanter, buttock or lateral thigh that may mimic the symptoms of lumbar nerve root compression. Despite these known features, the diagnosis of GTPS is often missed, and documentation of its prevalence in an orthopedic spine specialty practice is lacking. PURPOSE: To determine the prevalence of the GTPS in patients referred to a tertiary care orthopedic spine referral center for the evaluation of low back pain, and to describe the demographic and clinical characteristics of patients with this syndrome. STUDY DESIGN/SETTING: Retrospective analysis. Patient sample: A total of 247 consecutive patients referred for low back pain from August 1998 through December 2000. OUTCOME MEASURES: Clinical response to injection, demographic characteristics, physical examination findings, prevalence of GTPS and preexisting diagnostic evaluations. METHODS: The diagnosis of GTPS was made based on history and physical examination and was confirmed by response to anesthetic corticosteroid injection. Demographic and clinical characteristics of the study group were evaluated. Follow-up data were available at a mean of 8 weeks postinjection (range, 2 to 48 weeks). RESULTS: The prevalence of GTPS was 20.2% (51 of 252). Mean age (54 years) was the same for patients with (range, 25 to 85 years) and without (range, 17 to 85 years) GTPS. Significantly more women than men had GTPS (p<.03). Of the 51 patients diagnosed with GTPS at initial presentation, 54.9% (28 of 51) had already obtained a magnetic resonance imaging examination (although only 15.7%, ie, 8 of 51, demonstrated objective neurologic findings) and 62.7% (32 of 51) had previously been evaluated by an orthopedist or neurosurgeon; one patient had undergone two lumbar decompressions without clinical improvement before our evaluation. CONCLUSIONS: GTPS accounts for a substantial proportion of patients referred to our center for evaluation of low back pain. Both primary care physicians and specialty surgeons may miss this diagnosis, most common in middle-aged women. Accurate recognition of this problem earlier in the evaluation of patients with low back, buttock or lateral thigh symptoms may dramatically reduce costly patient referrals and diagnostic tests and may prevent unwarranted surgery.     

Long-Term Outcome of Patients Suffering from Clinical Instability after Microsurgical Treatment of Lumbar Disc Herniation

Summary A total of 39 patients suffering from clinical instability of the lumbar spine after microdiscectomy were evaluated for their long-term outcome. Included there were 21 (54%) male and 18(46%) female patients with a mean age of 55 years. All had been operated on for a virgin single-level lumbar disc herniation between the years 1985–1989 and they were evaluated for the presence of lumbar instability in 1991. Clinical signs and symptoms of segmental instability were then detected in all patients, with the symptom of "apprehension" positive in 30. During the follow-up, 2 (5%) patients had been treated by lumba spondylodesis. At the time of the present investigation, both of them gave the information that their low back pain and sciatica had diminished as compared to the prediscectomy situation; both were retired. The symptom of "apprehension" was negative in both. Of the remaining 37 patients, low back pain had completely recovered in 4 (11%) and diminished in 23 (62%) patients, while in 9 (24%) patients, back pain had remained unchanged and become worse in 1 (3%). Further, sciatica had completely recovered in 4 (11%) and diminished in 23 (62%) patients, while in 7 (19%) patients, sciatica had remained unchanged and become worse in 3 (8%). Only 14 (38%) of these patients were able to work. However, evaluated by the Oswestry Index, the overall outcome in daily activities had significantly improved in all 37 patients since 1991 (p=0.01). The symptom of "apprehension" was now positive in 26 patients. A significant correlation was observed between the positivity of this test and the persistence of low back pain (p=0.02) and a poor outcome in daily activities (p<0.0001). Comfirming earlier observations, the findings of this study support the concept that patients with postoperative lumbar instability have a poor prognosis. Further studies are needed to define the optimal treatment for this problematic patient group.     

Fibrous adhesive entrapment of lumbosacral nerve roots as a cause of sciatica.

STUDY DESIGN: Report of seven patients with fibrous adhesive entrapment of lumbosacral nerve roots as a cause of sciatica, whose radiographic findings were negative and who experienced relief from sciatica immediately after the entrapment was released. OBJECTIVES: To describe a new clinical entity of fibrous adhesive entrapment of lumbosacral nerve roots with negative radiographic findings. SETTING: Orthopaedic department, Japan. METHODS: Clinical evaluation and post-operative outcome in seven patients with entrapment of lumbosacral nerve roots because of fibrous adhesion confirmed intraoperatively. RESULTS: Radiographic examinations by magnetic resonance imaging (MRI), myelography, and computed tomographic (CT) myelography demonstrated neither disc herniations nor spinal stenosis in all seven patients, and differential nerve root block was effective for relieving sciatica and low back pain. We confirmed, intraoperatively, entrapment of the nerve root by fibrous adhesion, and all seven patients were relieved from sciatica and low back pain postoperatively. CONCLUSION: This study presented seven patients with sciatica caused by fibrous adhesive entrapment of lumbosacral nerve roots who underwent decompression and release of fibrous adhesion. Radiographic examinations, such as MRI, myelography and CT myelography, showed no compressive shadows and also differential nerve root block was effective for its diagnosis. This study seems to be the first report of patients with entrapment of lumbosacral nerve roots caused by fibrous adhesion, whose radiographic findings were negative.     

Evaluation and treatment of chemonucleolysis failures

Fifty patients underwent chemonucleolysis for the treatment of lumbar disk herniations unresponsive to conservative therapy. In patients treated with chymopapain, unrelieved sciatica was the most common cause of clinical treatment failure. Eight patients (16%) experienced no relief or only a transient reduction in their radicular symptoms following chymopapain injection. All eight patients were clinically reevaluated and underwent repeat neuroradiographic studies. Computed axial tomography and lumbar myelography demonstrated persistent nerve root compromise at the level of the injected disk space. Open diskectomy was performed in all eight cases. Postoperatively, seven patients noted complete resolution of their radicular symptoms; one patient had intermittent low back and leg pain following surgery.     

Assessing outcome in lumbar disc surgery using patient completed measures

Measuring outcome after spinal surgery is difficult. The objective of this study was to assess the use of four measures in establishing outcome in patients undergoing lumbar discectomy. Forty-six consecutive patients who had undergone two operations for lumbar disc prolapse and 54 patients who had undergone one operation for the same condition over the same period were identified. The SF-36 questionnaire was used to assess general health. The Roland-Morris questionnaire and a simple modification of the Roland-Morris questionnaire were used to assess back and leg related disability, respectively. Analogue pain scales were used to measure back pain and sciatica. The SF-36 scores revealed significantly worse health status in the two operation compared with the one operation patients and in all patients compared with the normal population. Using the Roland-Morris and the leg disability questionnaires, patients who had undergone two operations reported significantly worse disability (Roland-Morris, 53%, poor outcome) than those who had undergone one operation (Roland-Morris, 19%, poor outcome). There was significantly greater back disability than leg disability in both groups of patients and this was confirmed by the analogue pain scales. In patients who had undergone two operations, 25% classified their back pain as very bad or unbearable, and 22.5% described very bad or unbearable leg pain. For the one operation patients these figures were 9.5 and 2.4%, respectively. The results demonstrate that both generic and condition specific patient completed measures have the potential to detect differences in outcome between patients who have undergone either one or two lumbar disc operations. The study provides support for the use of these patient completed measures in assessing outcome in lumbar disc surgery.     

Painful sciatic rubbing caused by benign synovioma of the spinal joints. Apropos of 4 cases

Synovioma, a benign neoplasm arising from pigmented villonodular synovium or synovitis, is uncommon. It involves the tendons and joints of the finger, ankle and foot. In this study four cases of villonodular synovioma of spinal joints are reported. The authors studied 555 cases of patients operated for sciatica due to herniated disk. Histopathology showed that in four out of 555 cases sciatica was found to be due to synoviomas of the spinal joints. The patients, three women and one man, were between 54 and 70 years of age and each had had a long history of low back pain with episodes of sciatica. Clinical evaluation at the time of surgery showed moderate severity of signs and symptoms. Roentgenographic studies of all four cases revealed osteoarthritic changes of vertebral apophyses, with two cases of spondylolisthesis. The pathogenesis of synovioma remains controversial and its histopathological characterization -hyperplasia VS/true tumours- has not yet been determined. It is possible that the number of recorded cases of sciatica due to synoviomas is small because surgical and pathological studies in patients with sciatica associated with osteoarthritic changes have not been adequately performed. Surgery consists of a large resection of the capsule and ligament including resection of intraspinal extension. Because this study involves only four cases, the first of which occurred in 1977, the possibility of recurrence cannot be evaluated.     

Corticosteroids in peri-radicular infiltration for radicular pain: a randomised double blind controlled trial. One year results and subgroup analysis

The objective of this study is to evaluate the efficacy of corticosteroids in patients with radicular pain due to lumbar disc herniation or lumbar spinal stenosis through a prospective randomised, double blind controlled trial, and whether there was an effect on subsequent interventions such as additional root blocks or surgery. Peri-radicular infiltration of corticosteroids has previously been shown to offer no additional benefit in patients with sciatica compared to local anaesthetic alone. It is not known if the response to peri-radicular infiltration is less marked in certain subgroups of patients such as those with radicular pain due to lumbar spinal stenosis. Previous studies have suggested that peri-radicular infiltration of corticosteroids may obviate the need for subsequent interventions and we therefore further investigated this in the current study. We randomised 150 patients to receive a single injection with either bupivacaine alone or bupivacaine and methylprednisolone. Patients were assessed at 6 weeks and 3 months after the injection using standard outcome measures including Oswestry Disability Index (ODI), visual analogue score for leg pain and patient’s subjective assessment of outcome. At 1-year follow-up, we looked at the outcome in terms of the need for subsequent interventions such as additional root blocks or surgery. At 3-month follow-up, there was no statistically significant difference in the standard outcome measures between the two injection groups. At a minimum 1-year post injection, there was no difference in the need for subsequent interventions in either group. Patients with lumbar spinal stenosis had a less marked reduction in the ODI at 3 months with a mean change of 3.3 points when compared with 15 points for patients with lumbar disc herniation. In conclusion, peri-radicular infiltration of corticosteroids for sciatica does not provide any additional benefit when compared to local anaesthetic injection alone. Corticosteroids do not obviate the need for subsequent interventions such as additional root blocks or surgery.     

Surgical treatment of Bertolotti's syndrome

Summary We surgically treated 16 patients with Bertolotti's syndrome (chronic, persistent low back pain and radiographically diagnosed transitional lumbar vertebra). Eight had posterolateral fusion and another eight resection of the transitional articulation. Thirteen patients had in addition to the chronic low back pain, suffered from repeated episodes or chronic sciatica. In six cases with resection treatment, local injections were administered at the transitional articulation before deciding for resection of the transitional joint; each patient reported transient relief of pain, while this preoperative test did not correlate with successful outcome of treatment. Six patients had to be treated with second operations. Ten of the 16 operatively treated patients showed improvement of the low back pain, and this result was similar in the group treated with fusion and in that treated with resection. Seven had no low back pain at follow-up, and the improvement according to the Oswestry pain scale was similar in the two groups, and statistically significant. Eleven patients still had persisting episodes of sciatica (versus 13 preoperatively). The average disability according to the Oswestry total disability scale was 30%, corresponding with moderate outcome, and both operatively treated groups did equally well. At follow-up the first disc above the fused segments was found to be degenerated in seven out of eight cases, and in the group treated with resection the first disc above the transitional vertebra was degenerated in five cases. As conservatively treated controls, we had 16 comparable, but not randomly chosen patients whose age and type and duration of pain prior to the first clinical examination, and the length of follow-up were similar to those in the operatively treated group. The operatively treated patients had slightly better Oswestry pain score (mean 1.9 versus 2.5; statistically significant), while in regard to the total Oswestry disability scale, the results did not differ. We suggest operative treatment only to very selected patients with Bertolotti's syndrome. Patients with no disc deneration and whose chronic pain is truly associated with the transitional joint may be treated with resection of the transverse process. Patients with similar pain and with degeneration of the disc below but not above the transitional vertebra may have alleviation of pain and disability after posterolateral fusion.     

Agreement of self-reported items and clinically assessed nerve root involvement (or sciatica) in a primary care setting

Introduction

We analysed baseline measures from an RCT involving adults with low back pain (LBP) with or without referred leg pain, to identify self-report items that best identified clinically determined nerve root involvement (sciatica).

Methods

Potential indicators of nerve root involvement were gathered using a self-reported questionnaire. Participants underwent a standardised physical examination on the same day as questionnaire completion. Self-reported items were compared to a reference standard (clinical diagnosis) using sensitivity, specificity, predictive values, likelihood ratios (LRs), the area under the receiver operating characteristic curve and logistic regression. Two reference standards are presented: one based on a clinical diagnosis of nerve root problems and excluding possible/inconclusive cases (referred to as a confirmatory reference), and the other being inclusive of possible/inconclusive cases (referred to as an indicative reference).

Results

Pain below knee was the best single item for diagnostic accuracy with an area under curve (AUC) of 0.67–0.68, which however is slightly less than the ‘acceptable discrimination’. A cluster of three items, including distribution of pain below the knee, leg pain that is worse than back pain, and feeling of numbness or pins and needles in the leg, did improve discrimination to an ‘acceptable’ level with an AUC of 0.72–0.74 in relation to confirmatory and indicative references, respectively. However, the likelihood ratios from the models were reflective of a ‘small’ amount of discrimination.

Conclusion

In this primary care population seeking treatment for LBP with or without leg pain, we found no clear set of self-report items that accurately identified patients with nerve root pain. When accurate case definition is important, clinical assessment should be the method of choice for identifying LBP with possible nerve root involvement.     

Back pain's association with vertebral end-plate signal changes in sciatica

Background contextPatients with sciatica frequently experience disabling back pain. One of the proposed causes for back pain is vertebral end-plate signal changes (VESC) as visualized by magnetic resonance imaging (MRI).PurposeTo report on VESC findings, changes of VESC findings over time, and the correlation between VESC and disabling back pain in patients with sciatica.Study design/settingA randomized clinical trial with 1 year of follow-up.Patients samplePatients with 6 to 12 weeks of sciatica who participated in a multicenter, randomized clinical trial comparing an early surgery strategy with prolonged conservative care with surgery if needed.Outcome measuresPatients were assessed by means of the 100-mm visual analog scale (VAS) for back pain (with 0 representing no pain and 100 the worst pain ever experienced) at baseline and 1 year. Disabling back pain was defined as a VAS score of at least 40 mm.MethodsPatients underwent MRI both at baseline and after 1 year follow-up. Presence and change of VESC was correlated with disabling back pain using chi-square tests and logistic regression analysis.ResultsAt baseline, 39% of patients had disabling back pain. Of the patients with VESC at baseline, 40% had disabling back pain compared with 38% of the patients with no VESC (p=.67). The prevalence of type 1 VESC increased from 1% at baseline to 35% 1 year later in the surgical group compared with an increase from 3% to 11% in the conservative group. The prevalence of type 2 VESC decreased from 40% to 29% in the surgical group while remaining almost stable in the conservative group at 41%. The prevalence of disabling back pain at 1 year was 12% in patients with no VESC at 1 year, 16% in patients with type 1 VESC, 11% in patients with type 2 VESC, and 3% in patients with both types 1 and 2 VESC (p=.36). Undergoing surgery was associated with increase in the extent of VESC (odds ratio [OR], 8.6; 95% confidence interval [CI], 4.7–15.7; p<.001). Patients who showed an increase in the extent of VESC after 1 year did not significantly report more disabling back pain compared with patients who did not show any increase (OR, 1.2; 95% CI, 0.6–2.6; p=.61).ConclusionIn this study, undergoing surgery for sciatica was highly associated with the development of VESC after 1 year. However, in contrast with the intuitive feeling of spine specialists, those with and those without VESC reported disabling back pain in nearly the same proportion. Therefore, VESC does not seem to be responsible for disabling back pain in patients with sciatica.