脊神经背支内侧支射频损毁治疗慢性下腰痛的临床效果评估

目的观察比较脊神经背支内侧支射频损毁和单纯神经阻滞治疗小关节源性下腰痛的效果,评估射频神经损毁的疗效和安全性。方法影像学检查显示腰椎小关节退行性变、主诉下腰痛向臀部和/或大腿放射的患者56例,分为脊神经背支内侧支神经阻滞组(medial branch block,MBB,n=32)和射频损毁组(radiofrequency,RF,n=24)。结果治疗后4周RF组疼痛缓解的成功率(79.17%)明显高于MBB组(68.75%)(P＜0.05)。36周后两组疼痛复发的病例百分比无明显差异(P＞0.05),但是36周内疼痛复发患者的疼痛缓解持续时间RF组(31±16.5)周明显长于MBB组(17.4±8.6)周(P＜0.05)。RF组少数患者治疗后2周内可能出现局部麻木、不适,甚至疼痛加剧,2周后几乎完全缓解。结论与单纯神经阻滞相比,脊神经背支内侧支射频损毁治疗小关节源性下腰痛具有疗效好、持续时间长的优点,而且并发症少。     

Workplace stress, lifestyle and social factors as correlates of back pain: a representative study of the German working population

OBJECTIVES: To investigate the prevalence of back pain in the German working population and the relationship between back pain and workplace stresses, lifestyle and social factors. METHODS: The first National Health Survey of the Federal Republic of Germany was carried out between October 1997 and March 1999. It comprised a representative epidemiological cross-sectional study of the working population, with a total sample of 3,488 persons between the ages of 18 and 69 years. The participants took part in a medical examination and answered a self-rating questionnaire. The relationship between subjective back pain and workplace stresses and social and lifestyle factors was investigated with bivariate tests and multiple logistical regression analyses. RESULTS: The 7-day prevalence for back pain in the German working population was found to be 34%, and the 1-year prevalence was 60%. The odds ratios were significantly higher in women, persons of lower socioeconomic status, married and depressed persons and non-athletes. Carrying heavy loads or maintaining a single working posture were the most significant work-related correlates of back pain, for members of both the female and male working population, while environmental stress and psychological stress correlated significantly with back pain in men only. CONCLUSIONS: This study reports the first representative epidemiological prevalence data for back pain, and its correlates and potential risk factors, for the German working population. To reduce the negative impact of back pain the most promising behavioural and conditional prevention measures in the workplace would be to reduce carrying stress and to vary working posture. In addition, a more active, athletic lifestyle, plus the avoidance of being overweight, should provide an additional protective or preventive effect.     

The costs for persons sick-listed more than one month because of low back or neck problems. A two-year prospective study of Swedish patients

The total costs for patients who are sick-listed due to back and neck problems have not previously been determined prospectively on an individual basis. This study aimed to determine the total cost to a society, based on individually assessed costs of health services and loss of production in people who are sick-listed 28 days or more for back or neck problems. Detailed data on individuals health-care consumption due to back or neck problems was collected through prospectively entered diaries and questionnaires, after 4 weeks, 3 months, 1 and 2 years, in a consecutively selected cohort of 1,822 employed persons aged between 18 and 59 years. Costs for health care and production losses due to work absenteeism were determined individually and combined to render total costs to society. The costs for all medical services during the 2-year study were 6.9% of total costs for back and neck problems. The single most expensive medical service was surgery. Transferred to a national level, annual total costs for back and neck problems corresponded to 1% of GNP. In conclusion, direct health-service costs were a small fraction of the total costs, consequently indirect costs offer the greatest potential for savings.     

Treatment duration and cost of work-related low back pain in Korea

The purpose of this study is to present the information on the duration of treatment and the cost of work-related low back pain. Using the compensation-database for 1997 work-related low back pain (n=9,277), this study estimated the duration of treatment, the cost of work-related low back pain, the relationship between them, and probability of being off treatment at different intervals. The mean and the median of the treatment duration are 252.6 days and 175 days. The mean and the median of the cost of total insurance benefit are 37,700,000 won and 14,400,000 won. The treatment duration of 51% of the study subjects was less than 6 months and their cost accounted for 10.2% of the total insurance benefit. The subjects who were treated more than 24 months were 5.8% but it accounted for 29.2% of the cost. It was found that approximately 50% of the subjects who will remain on treatment at the end of n months would be off treatment at the end of n+5 months. This study presents the point in time when the low back pain (LBP) workers need to prepare to return to work by forecasting their off-treatment period. From the treat duration and cost perspectives, this study may be utilized as evidence for active management of work-related LBP.     

Sitting and standing tolerance in patients with chronic back pain: comparison between physician prediction and covert observation

OBJECTIVES: To measure covertly observed continuous sitting and standing tolerance in patients with chronic back pain and to compare observations to physician predictions. DESIGN: Blinded, prospective, cohort study. SETTING: Ambulatory referral centers, both public and private, at 5 major medical centers in the eastern United States. PARTICIPANTS: All volunteers (N=154; 64.0% women, mean age, 48.7y; 16.8% had active lawsuits) with diagnosis codes of the International Classification of Diseases, 9th Revision consistent with thoracic and/or lumbosacral back pain were selected from a cohort of 651 outpatients with chronic pain enrolled in the Multiperspective Multidimensional Pain Assessment Protocol (MMPAP). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Continuous sitting and standing tolerance was measured by (1). covert observation of subjects during the MMPAP trial and (2). blinded expert physician prediction based on complete history and physical examination. RESULTS: Most (124/154, 80.5%) subjects stood for 30 minutes or more and most (124/154, 80.5%) sat for 60 minutes or more. Overall, physicians underpredicted the ability to sit 60 minutes or more and to stand 30 minutes or more. Physician prediction showed poor correlation to covert observation for sitting tolerance (kappa=-.061, P=.221) and standing tolerance (kappa=-.021, P=.727). CONCLUSIONS: The majority of this sample demonstrated the ability to sit continuously 60 minutes or more and to stand continuously 30 minutes or more while being covertly observed. Expert physician prediction showed poor correlation to covertly observed sitting and standing tolerances, raising doubt about the validity of using physician evaluation to establish work restrictions in patients with chronic back pain. These findings are preliminary, follow only a brief period of covert observation, and indicate the need for further research in this area.     

Determination of the usage of body mechanics in clinical settings and the occurrence of low back pain in nurses

This explorative study was designed to identify the usage of body mechanics in clinical settings and the occurrence of low back pain in nurses. The sample was composed of 56 nurses who work on the medical, surgical, emergency and intensive care units of a state hospital in Bolu, Turkey. Data collected through observation and interviews were evaluated using percentages, Chi-square and Mann-Whitney U tests. Results of the study showed that the majority of the nurses (87.5%) experienced low back pain at some time in their lives. Among the contributing factors for back pain, the relationship between wearing high heels, heavy lifting and back pain was significant statistically. According to the observations, the majority of the nurses used body mechanics correctly while sitting (53.6%), standing (58.7%), carrying (64.3%), pulling or pushing (79.4%), moving the patient to the side of the bed without an assistant (53.4%), moving the patient to a sitting position in bed (71.4%) and assisting the patient to a standing position (66.6%). However 57.1% of the nurses lifted and 82% extended incorrectly. The conclusion from this research was that some of the nurses do not use body mechanics correctly and the majority have low back pain.     

Cost-utility analysis of osteopathy in primary care: results from a pragmatic randomized controlled trial

BACKGROUND: Spinal pain is common and costly to health services and society. Management guidelines have encouraged primary care referral for spinal manipulation, but the evidence base is weak. More economic evaluations alongside pragmatic trials have been recommended. OBJECTIVE: Our aim was to assess the cost-utility of a practice-based osteopathy clinic for subacute spinal pain. METHODS: A cost-utility analysis was performed alongside a pragmatic single-centre randomized controlled trial in a primary care osteopathy clinic accepting referrals from 14 neighbouring practices in North West Wales. Patients with back pain of 2-12 weeks duration were randomly allocated to treatment with osteopathy plus usual GP care or usual GP care alone. Costs were measured from a National Health Service (NHS) perspective. All primary and secondary health care interventions recorded in GP notes were collected for the study period. We calculated quality adjusted life year (QALY) gains based on EQ-5D responses from patients in the trial, and then cost per QALY ratios. Confidence intervals (CIs) were estimated using non-parametric bootstrapping. RESULTS: Osteopathy plus usual GP care was more effective but resulted in more health care costs than usual GP care alone. The point estimate of the incremental cost per QALY ratio was 3560 pounds (80% CI 542 pounds-77,100 pounds). Sensitivity analysis examining spine-related costs alone and total costs excluding outliers resulted in lower cost per QALY ratios. CONCLUSION: A primary care osteopathy clinic may be a cost-effective addition to usual GP care, but this conclusion was subject to considerable random error. Rigorous multi-centre studies are needed to assess the generalizability of this approach.     

Efficacy and cost-effectiveness of environmental management for malaria control

Roll back malaria (RBM) aims at halving the current burden of the disease by the year 2010. The focus is on sub-Saharan Africa, and it is proposed to implement efficacious and cost-effective control strategies. But the evidence base of such information is scarce, and a notable missing element is the discussion of the potential of environmental management. We reviewed the literature and identified multiple malaria control programmes that incorporated environmental management as the central feature. Prominent among them are programmes launched in 1929 and implemented for two decades at copper mining communities in Zambia. The full package of control measures consisted of vegetation clearance, modification of river boundaries, draining swamps, oil application to open water bodies and house screening. Part of the population also was given quinine and was sleeping under mosquito nets. Monthly malaria incidence rates and vector densities were used for surveillance and adaptive tuning of the environmental management strategies to achieve a high level of performance. Within 3-5 years, malaria-related mortality, morbidity and incidence rates were reduced by 70-95%. Over the entire 20 years of implementation, the programme had averted an estimated 4173 deaths and 161,205 malaria attacks. The estimated costs per death and malaria attack averted were US$ 858 and US$ 22.20, respectively. Over the initial 3-5 years start-up period, analogous to the short-duration of cost-effectiveness analyses of current studies, we estimated that the costs per disability adjusted life year (DALY) averted were US$ 524-591. However, the strategy has a track record of becoming cost-effective in the longer term, as maintenance costs were much lower: US$ 22-92 per DALY averted. In view of fewer adverse ecological effects, increased sustainability and better uses of local resources and knowledge, environmental management--integrated with pharmacological, insecticidal and bednet interventions--could substantially increase the chances of rolling back malaria.     

椎间盘源性下腰痛

慢性下腰痛是普遍存在的健康问题,其中40%是椎间盘源性下腰痛,而大部分医师对其认识不足,易造成误诊。本文从病史、流行病学、病因、发病机制、临床表现和治疗等方面对该病进行综述,以提高临床对此病的认识。     

The influence of a chiropractic manipulation on lumbar kinematics and electromyography during simple and complex tasks: a case study

OBJECTIVE: To investigate whether a more sophisticated and detailed analysis of both simple and complex tasks may yield more information regarding the short-term influence of an adjustment on spine biomechanics. METHODS: The study used a single-subject, before-after design. Three-dimensional spine kinematics and trunk muscle electromyography were assessed during a variety of tasks performed by a professional golfer exhibiting non-specific, chronic, low back pain. The patient received a right-to-left and left-to-right spinous pull adjustment. RESULTS: After the adjustment, changes were seen in all 3 axes of motion during a golf swing, with concomitant muscle responses. In addition, changes in the off axes of motion were seen during simple movement tasks. CONCLUSIONS: A more detailed spine kinematic analysis, specifically analysis of motion in the nonprincipled axes, yielded more information regarding the short-term influence of an adjustment on lumbar spine motion and muscle function.