臭氧与等离子射频消融术治疗慢性椎间盘源性腰痛对比研究

[目的]比较臭氧及等离子射频消融技术治疗经保守治疗无效的慢性椎间盘源性腰痛的初步临床疗效.[方法]208例经保守治疗无效的慢性腰痛患者,术前椎间盘经造影显示为阳性,随机分别用臭氧射频消融术(A组)及等离子射频消融术(B组)治疗,其中A组95例:男47例,女48例,平均年龄35.5(17～55)岁,病程7～118个月;B...     

Comparative Evaluation of Oxygen‐Ozone Therapy and Combined Use of Oxygen‐Ozone Therapy with Percutaneous Intradiscal Radiofrequency Thermocoagulation for the Treatment of Lumbar Disc Herniation

Aim: To compare the efficacy of oxygen‐ozone therapy and the combined use of oxygen‐ozone therapy with percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) for the treatment of contained lumbar disc herniation. Methods: Ninety‐one adult patients with low back pain secondary to contained lumbar disc herniation were randomly assigned into two groups. Ozone group received intradiscal oxygen‐ozone therapy (4 to 7 mL of oxygen ozone mixture); ozone‐PIRFT group received a combination of oxygen‐ozone therapy with PIRFT (radiofrequency lesioning at 80°C for 360 s). Outcome Measures: Primary outcome measures included a visual analog scale (VAS) for pain and the Oswestry disability index (ODI). Secondary outcome measures included pain relief, reduction of analgesic consumption, and patient's satisfaction. Clinical assessment of these outcome measures was performed at 2 weeks, 1 month, 3 months, 6 months, and 1 year after the procedure. Results: VAS scores and ODI were significantly decreased by both ozone and ozone‐PIRFT when compared with the baseline values at all points of follow‐up; however, ozone‐PIRFT produced a significant reduction in the VAS scores and ODI when compared to ozone at 2 weeks, 1 month, 3 months, 6 months, and 1 year follow‐up. Ozone‐PIRFT also resulted in a significant change in all secondary measures at all points of follow‐up, as compared with the ozone group. Conclusion: Ozone‐PIRFT is more efficacious than ozone alone in reducing pain scores, analgesic consumption, improving functional outcome, and satisfaction of patients with contained lumbar disc herniation.     

Interventional Pain Management for Failed Back Surgery Syndrome

Patients who suffer from the condition known as failed back surgery syndrome (FBSS) present to the offices of physicians, surgeons, and pain specialists alike in overwhelming numbers. This condition has been defined as persistent back and/or leg pain despite having completed spinal surgery. As lumbar surgery continues to grow in prevalence, so will the number patients suffering from FBSS. It is important for physicians treating this population to expand their knowledge of FBSS etiologies and appropriate diagnostic imaging modalities, combined with confirmatory diagnostic injections, and proper technique for interventional pain procedures. In doing so, the physician may adequately be prepared to manage these complex cases in the future, ideally with the support of stronger evidence. Management begins with a systematic evaluation of common FBSS etiologies such as new‐onset stenosis, recurrent herniated nucleus pulposus (HNP), epidural fibrosis, pseudarthrosis, and others. History and physical may be supplemented by imaging including X‐ray, magnetic resonance imaging, or computed tomography myelography. Certain diagnoses may be confirmed with diagnostic procedures such as intra‐articular injections, medial branch blocks, or transforaminal nerve root blocks. Once an etiology is determined, a multidisciplinary approach to treatment is most effective. This includes exercise or physical therapy, psychological counseling, medication, and interventional procedures. The most invasive treatment option, short of revision surgery, is spinal cord stimulation. This intervention has a number of studies demonstrating its efficacy and cost‐effectiveness in this population. Finally, revision surgery may be used when indicated such as with progressive neurological impairment or with issues regarding previous surgical instrumentation.     

Investigation of nonmechanical findings during spinal movement screening for identifying and/or ruling out metastatic cancer

Study design: Retrospective cohort study. Objective: To investigate the diagnostic accuracy of lumbar movement restrictions and pain in patients with metastatic bone cancer. Background: When evaluating patients with low back pain, physical therapists have used the presence of nonmechanical findings during a spinal movement screen as 1 factor in determining whether physician referral is necessary. There are no studies that have investigated the accuracy of this strategy in a situation of diagnostic uncertainty. Methods: This study included 1,109 patients (655 women) with low back pain (mean age = 54.8 ± 16.3 years) seen at a spine surgery center who received a clinical movement screen and an imaging‐supported diagnosis by an orthopedic surgeon. No report of pain during movement and no limitation of movement were considered the 2 targeted findings as these are associated with nonmechanical findings. Results: Sixty‐six patients were diagnosed with metastatic cancer, 61 with metastatic bone cancer and concomitant diagnoses. Pain‐free lumbar movements in all directions for patients with metastatic bone cancer without concomitant diagnoses were associated with a posttest probability of 0.00 (+likelihood ratio = 2.4; ?likelihood ratio = 0.0), which may be useful in ruling out spinal cancer. In situations where a concomitant diagnosis was present with cancer, the value of a movement screen was poor. Conclusion: Nonmechanical findings during a traditional movement screen are not specific to sinister conditions such as metastatic spinal cancer. Clinicians should expect concomitant conditions to exhibit painful or limited findings in patients with and without cancer.     

Is Spinal Cord Stimulation an Effective Treatment Option for Discogenic Pain?

Introduction: In a prospective observational study conducted in an urban pain management center, we evaluated whether spinal cord stimulation (SCS) is effective in relieving discogenic pain of IDD origin. Methods: Thirteen patients with intractable discogenic low back pain were enrolled. Four patients never underwent permanent implantation due to insurance denial, medical reasons or failed trial and served as a control group. Nine patients underwent SCS implantation (treatment group). All patients were followed for 12 months and assessed at each interval for pain (NRS), disability (ODI), and opioid use. Results: Nine patients completed the SCS trial with > 50% pain relief. The pretrial NRS score was 7.8 ± 0.5 mm in treated patients vs. 6.5 ± 1.7 mm in control patients. At 3, 6 and 12 months, the NRS was reduced to 2.9 ± 0.7 mm, 1.7 ± 0.5 mm, and 2.9 ± 0.5 mm, respectively in treated patients. NRS was unchanged in the control patients (6.5 ± 1.9 mm). The ODI score prior to the SCS trial in treated patients was 53.1 ± 3.4% vs. 54.0 ± 20.5 in control patients. At 3, 6 and 12 months the ODI scores were 39.0 ± 8.0%, 38.7 ± 4.6%, and 41.1 ± 3.9%, respectively in the treated patients, and 48.5 ± 29.5 at 12 months in control patients. In 6 patients receiving opioids prior to the SCS trial, average consumption was reduced by 69% (P = 0.036) over 12 months of therapy as compared with a 54% increase in the control patients. SCS usage was stable over the 12‐month study. Conclusions: The current study indicates that SCS may provide effective pain relief, improve disability, and reduce opioid usage in patients with discogenic pain.     

Differences in Comorbidities on Low Back Pain and Low Back Related Leg Pain

Objective: Investigate the influence of external factors such as depression and BMI among subjects with primary severe low back pain (LBP) and low back related leg pain (LBLP). Background: The report of disability in patients with LBP may be significantly influenced by confounding and moderating variables. No similar studies have examined the influence of these factors on LBLP. Methods: This study included 1,448 consecutive subjects referred to a tertiary spine clinic. Unconditional binary logistic regression was used to determine the influence of comorbidities on the relationship between self‐reported back and leg pain. A change in estimate formula was used to quantify this relationship. Results: Among those subjects with primary LBP the unadjusted odds ratio was 8.58 (95% CI 4.87, 15.10) and when adjusting for BMI, depression and smoking was 5.94 (95% CI 3.04, 11.60) resulting in a 36.7% change due to confounding by these comorbidities. Among those with primary LBLP, the unadjusted odds ratio was 4.49 (95% CI 2.78, 7.27) and when adjusting for BMI and depression was 4.60 (95% CI 2.58, 8.19) resulting in a 1.7% change due to confounding by these comorbidities. Conclusion: The disability statuses of the patients with primary LBP in this study were more significantly affected by comorbidities of BMI, depression and smoking than patients with report of LBLP. However, these comorbidities contribute little to the relationship of primary low back related leg pain and Oswestry scores ≥ 40.     

Analyzing chronic low back pain: the relative contribution of pain coping strategies

Sixty-two chronic low back pain patients were administered the Coping Strategies Questionnaire (CSQ) to assess the frequency of use and perceived effectiveness of a variety of cognitive and behavioral pain coping strategies. Analysis of individual variables revealed that CSQ factors, gender, physical examination findings, and chronicity of pain had significant effects on one or more of a series of pain, psychological distress or behavioral measures. To assess the relative contribution of each of these variables hierarchical stepwise regression analyses were carried out. These analyses revealed that the Helplessness factor of the CSQ explained 50% of the variance in psychological distress (Global Severity Index of the SCL-90R), and 46% of the variance in depression (Beck Depression Inventory). Patients scoring high on this CSQ factor had significantly higher levels of psychological distress. None of the demographic or medical status variables explained a significant proportion of variance in the psychological distress measures. The Diverting Attention and Praying factor of the CSQ explained a moderate (9%), but significant amount of variance in pain report. Patients scoring high on this factor had higher scores on the McGill Pain Questionnaire. Coping strategies were not strongly related to pain behavior measures such as guarding or uptime. A consideration of pain coping strategies may allow one to design pain coping skills training interventions so as to fit the needs of the individual low back pain patient.     

Opioids Versus Physical Therapy for Management of Chronic Back Pain

Chronic low back pain (CLBP) is a common disabling disorder managed by a variety of interventions. The purpose of this article was to review the literature and critique the evidence to determine if opioid analgesics improved patient outcomes compared with physical therapy. No research was found that directly compared the efficacy of opioid analgesics with physical therapy. Although the evidence supports the use of physical therapy in chronic back pain, the study results are conflicting regarding the usefulness of opioid analgesics in CLBP management. More research involving the efficacy of opioid analgesic in treating CLBP is needed.     

A national framework for supporting improvements in the physiotherapy assessment and management of low back pain: the Scottish experience

Background

Similar to other countries worldwide, Scotland lacked a national view of whether the quality of the physiotherapy management of low back pain was compliant with national guidelines. Anecdotal evidence suggested that standards of care varied considerably despite the wide availability of clinical guidelines to clinicians.

Aim

To develop a framework that supports National Health Service (NHS) Scotland in providing consistently applied high-quality physiotherapy assessment and management of low back pain in line with guideline recommendations.

Design

Prospective, multicentred national study, data collection and improvement phase.

Setting

All NHS boards in Scotland (n = 14) plus two private provider sites.

Participants

One hundred and eighty-six individual NHS sites and two private providers of services to patients with low back pain.

Method

A national dataset was developed from evidence- and consensus-based guideline sources. All sites collected data (two 5-week periods) over 1 year (2008-2009) using a web-based database. This was interspersed by an improvement phase during which required improvements were considered and implemented. Issues were shared through a national network and national meeting.

Results

Data from 2147 patients showed improvements in the documented physiotherapy management of low back pain over the two cycles. All participants developed and implemented remedial action plans based on the results of the first cycle.

Conclusion

It is possible to implement a framework, which is led nationally but driven and owned locally, supporting physiotherapists in an active programme of locally determined improvement. However, although process and outcome are linked, the direct impact of this initiative on patient outcome is not known.     

Effects of Qigong practice in office workers with chronic non-specific low back pain: A randomized control trial

ObjectiveTo investigate the effects of Qigong practice, Guan Yin Zi Zai Gong level 1, compared with a waiting list control group among office workers with chronic nonspecific low back pain (CNLBP).MethodsA randomized controlled trial was conducted at offices in the Bangkok Metropolitan Region. Seventy-two office workers with CNLBP were screened for inclusion/exclusion criteria (age 20–40 years; sitting period more than 4 h per day) and were allocated randomly into two groups: the Qigong and waiting list groups (n = 36 each). The participants in the Qigong group took a Qigong practice class (Guan Yin Zi Zai Gong level 1) for one hour per week for six weeks at their workstation. The participants were encouraged to conduct the Qigong exercise at home every day. The waiting list group received general advice regarding low back pain management. The primary outcomes were pain intensity, measured by the visual analog scale, and back functional disability, measured by the Roland and Morris Disability Questionnaire. The secondary outcomes were back range of motion, core stability performance index, heart rate, respiratory rate, the Srithanya Stress Scale (ST-5), and the global perceived effect (GPE) questionnaire.ResultsCompared to the baseline, participants in the Qigong group experienced significantly decreased pain intensity and back functional disability. No statistically significant difference in these parameters was found in the waiting list group. Comparing the two groups, Qigong exercise significantly improved pain intensity, back functional impairment, range of motion, core muscle strength, heart rate, respiratory rate, and mental status. The Qigong group also had a significantly higher global outcome satisfaction than the waiting list group.ConclusionQigong practice is an option for treatment of CNLBP in office workers.     

Are localized low back pain and generalized back pain similar entities? Results of a longitudinal community based study

Purpose.?To compare subjects with localized low back pain (LBP) and with generalized back pain (BP) with regard to baseline characteristics and long-term outcomes.

Methods.?A community-based longitudinal study. All inhabitants aged 22 – 70 of a single town were asked to complete self-administered questionnaires regarding back and neck pain and lifestyle characteristics. Those reporting LBP during the previous month were followed up after one year. Data were stratified by sites of pain with respect to ‘localized LBP’ and to ‘LBP with additional sites of BP’. Among LBP measures were the Roland and Morris Disability scale and Pain symptoms indices.

Results.?Nearly 30% of the total population (602) experienced LBP during the previous month, of whom more than half (336) reported ‘localized LBP’ and the rest LBP + neck and or upper back pain (Generalized BP). Both subgroups differed from those free of BP, however, those reported ‘Generalized BP’ comprised more females, were less educated, smoked more, were less engaged in sporting activities and reported higher level of LBP measures than those reported ‘localized LBP’. After one year, both subgroups were similar with regard to lifestyle but remained different with regard to some of the LBP measures.

Conclusions.?Subjects with ‘localized LBP’ presented healthier lifestyle than subjects with ‘Generalized BP’. The latter experienced higher degree of pain measures. It seems that ‘Generalized BP’ is not a different entity than ‘localized LBP’ but rather a more severe one.