Designing an implementation strategy to improve interprofessional shared decision making in sciatica: study protocol of the DISC study

ABSTRACT: BACKGROUND: Sciatica is a common condition worldwide that is characterized by radiating leg pain and regularly caused by a herniated disc with nerve root compression. Sciatica patients with persisting leg pain after six to eight weeks were found to have similar clinical outcomes and associated costs after prolonged conservative treatment or surgery at one year follow-up. Guidelines recommend that the team of professionals involved in sciatica care and patients jointly decide about treatment options, so-called interprofessional shared decision making (SDM). However, there are strong indications that SDM for sciatica patients is not integrated in daily practice. We designed a study aiming to explore the barriers and facilitators associated with the everyday embedding of SDM for sciatica patients. All related relevant professionals and patients are involved to develop a tailored strategy to implement SDM for sciatica patients. METHODS: The study consists of two phases: identification of barriers and facilitators and development of an implementation strategy. First, barriers and facilitators are explored using semi-structured interviews among eight professionals of each (para)medical discipline involved in sciatica care (general practitioners, physical therapists, neurologists, neurosurgeons, and orthopedic surgeons). In addition, three focus groups will be conducted among patients. Second, the identified barriers and facilitators will be ranked using a questionnaire among a representative Dutch sample of 200 GPs, 200 physical therapists, 200 neurologists, all 124 neurosurgeons, 200 orthopedic surgeons, and 100 patients. A tailored team-based implementation strategy will be developed based on the results of the first phase using the principles of intervention mapping and an expert panel. DISCUSSION: Little is known about effective strategies to increase the uptake of SDM. Most implementation strategies only target a single discipline, whereas multiple disciplines are involved in SDM among sciatica patients. The results of this study can be used as an example for implementing SDM in other patient groups receiving multidisciplinary complex care (e.g., elderly) and can be generalized to other countries with similar context, thereby contributing to a worldwide increase SDM in preference sensitive choices.     

经皮椎间孔镜联合超前镇痛的术后疼痛的疗效分析

目的:探讨经皮椎间孔镜联合盘内注射胶原酶对于椎间盘突出症术后疼痛的疗效。方法:选取我科收治的经皮椎间孔镜手术患者110例,将其随机分为观察组以及对照组,每组55例,观察组采取椎间孔镜联合盘内注射胶原酶联合超前镇痛治疗,对照组给予相同的手术方式联合术后口服药物治疗,连续治疗1个疗程后,比较两组患者术后4、12、24、48、72 h的疼痛评分,观察两组术后曲马多的用量,比较两组患者术后出现恶心、呕吐、嗜睡、便秘、皮肤瘙痒等并发症的发生情况,比较两组术前以及术后7、14d的JOA评分情况。结果:术后4、12、24、48、72 h观察组的疼痛评分均明显低于对照组,观察两组术后曲马多的用量明显少于对照组,观察组术后并发症的发生率为7.27%(4/55),对照组为30.91%(17/55),组间比较有明显差异(x2=13.624,P0.05),术后7 d观察组JOA评分明显优于对照组,P0.05,术后14 d组间比较无明显差异,P0.05。结论:塞来昔布超前镇痛措施应用于经皮椎间孔镜联合盘内注射胶原酶治疗腰椎间盘突出症术后患者能够有效缓解术后疼痛,并减少术后阿片类药物的使用,改善术后功能,值得临床推广应用。     

Stretching of the sciatic nerve; a means of relieving postoperative pain following removal of ruptured lumbar intervertebral discs

Stretching the sciatic nerve for the relief of "sciatica" was frequently employed before 1900 and was subsequently abandoned, probably because it was done without sufficient scrutiny of the indications. The procedure has recently been employed in cases in which "sciatica" remains following the operative removal of ruptured intervertebral discs, and it has been instrumental in relieving postoperative "sciatica" when the cause was the formation of adhesions about the lumbar nerve roots. If the nerve root is compressed by recurrent disc protrusion or by adjacent bone, the manipulation usually increases the pain, a phenomenon that has been helpful from a diagnostic standpoint.     

缺氧诱导因子-1α和血管内皮生长因子在突出腰椎间盘中的表达及意义

目的探讨缺氧诱导因子-1α（hypoxia—induciblefactor-1α,HIF-1α）和血管内皮生长因子（vascular endothelial growth factor,VEGF）在突出腰椎间盘组织中的表达及意义。方法采用链霉亲和素-过氧化物酶复合物（SABC）免疫组化方法,测定40例腰椎间盘突出症患者椎间盘组织中HIF-1α和VEGF的表达情况。结果退变椎间盘组织中HIF-1α和VEGF呈高表达,HIF-1α和VEGF在髓核的表达显著高于纤维环;纤维环破裂型显著高于纤维环完整型;各组中HIF-1α和VEGF的表达均高度相关。结论HIF-1α和VEGF共同参与了椎间盘退变;HIF-1α可能通过上调VEGF的表达来促进椎间盘组织中新生血管的形成,进而延缓椎间盘退变的发生。     

Nucleolytic action of chondroitinase ABC on the lumbar disc of the rabbit

Nucleolysis using chondroitinase ABC was studied using the rabbit's intervertebral lumbar disc. The purpose was to find a possible alternative to chymopapain which is commonly used in the management of sciatica due to disc herniation. The injection of 1 U of the enzyme into the nucleus pulposus gave significant histological and biochemical changes in all twelve discs studied.     

BMP13 Prevents the Effects of Annular Injury in an Ovine Model

Chronic back pain is a global health problem affecting millions of people worldwide and carries significant economic and social morbidities. Intervertebral disc damage and degeneration is a major cause of back pain, characterised by histological and biochemical changes that have been well documented in animal models. Recently there has been intense interest in early intervention in disc degeneration using growth factors or stem cell transplantation, to replenish the diseased tissues. Bone Morphogenetic Proteins (BMPs) have been approved for clinical use in augmenting spinal fusions, and may represent candidate molecules for intervertebral disc regeneration.     

SURGICAL TREATMENT OF CERVICAL OSTEOARTHRITIS

The early results of anterior cervical intervertebral disc excision and fusion (Cloward operation) together with removal of associated arthritic bone spurs pressing on nerves and spinal cord give promise of relief of pain and muscle weakness in patients who have this form of cervical osteoarthritis.Eighty-five per cent of a group of patients with neurologic pain caused by compression of this kind were relieved by this operation. The approach to the cervical vertebrae is made by an incision into the front of the neck and the diseased disc and arthritic spurs are removed by drilling a half-inch hole into the edges of the vertebrae. The remaining fragments of disc are curetted away. The hole is plugged with a bone dowel. The patients had less pain and a more rapid convalescence than with the usual posterior laminectomy for chronic disc disease.     

Enhancing intervertebral disc repair and regeneration through biology: platelet-rich plasma as an alternative strategy

Intervertebral disc degeneration (IDD) is a common orthopedic disease associated with mechanical changes that may result in significant pain. Current treatments for IDD mainly depend on conservative therapies and spinal surgeries that are only able to relieve the symptoms but do not address the cause of the degeneration and even accelerate the degeneration of adjacent segments. This has prompted research to improve our understanding of the biology of intervertebral disc healing and into methods to enhance the regenerative process. Recently, biological therapies, including active substances, gene therapy and tissue engineering based on certain cells, have been attracting more attention in the field of intervertebral disc repair and regeneration. Early selection of suitable biological treatment is an ideal way to prevent or even reverse the progressive trend of IDD. Growth factors have been enjoying more popularity in the field of regeneration of IDD and many have been proved to be effective in reversing the degenerative trend of the intervertebral disc. Identification of these growth factors has led to strategies to deliver platelet-derived factors to the intervertebral disc for regeneration. Platelet-rich plasma (PRP) is the latest technique to be evaluated for promoting intervertebral disc healing. Activation of the PRP leads to the release of growth factors from the α-granules in the platelet cytoplasm. These growth factors have been associated with the initiation of a healing cascade that leads to cellular chemotaxis, angiogenesis, synthesis of collagen matrix, and cell proliferation. This review describes the current understanding of IDD and related biological therapeutic strategies, especially the promising prospects of PRP treatment. Future limitations and perspectives of PRP therapy for IDD are also discussed.     

Gene expression profile analysis of human intervertebral disc degeneration

In this study, we used microarray analysis to investigate the biogenesis and progression of intervertebral disc degeneration. The gene expression profiles of 37 disc tissue samples obtained from patients with herniated discs and degenerative disc disease collected by the National Cancer Institute Cooperative Tissue Network were analyzed. Differentially expressed genes between more and less degenerated discs were identified by significant analysis of microarray. A total of 555 genes were significantly overexpressed in more degenerated discs with a false discovery rate of < 3%. Functional annotation showed that these genes were significantly associated with membrane-bound vesicles, calcium ion binding and extracellular matrix. Protein-protein interaction analysis showed that these genes, including previously reported genes such as fibronectin, COL2A1 and β-catenin, may play key roles in disc degeneration. Unsupervised clustering indicated that the widely used morphology-based Thompson grading system was only marginally associated with the molecular classification of intervertebral disc degeneration. These findings indicate that detailed, systematic gene analysis may be a useful way of studying the biology of intervertebral disc degeneration.     

LAMINECTOMY FOR HERNIATED INTERVERTEBRAL DISC

In a study of 59 patients surgically treated by various surgeons for relief of herniated lumbar intervertebral disc accompanied by symptoms that persistently recurred or had become resistant to conservative therapy, it was noted from review of hospital and office records that laminectomy either greatly relieved or entirely abated symptoms in 83 per cent of the cases.Postoperative complications reported by the surgeons who did the operations consisted of one death and five wound infections. Contrast myelography and electromyography, used in almost all cases in the series, appeared to be valuable adjuncts in the diagnosis of herniated lumbar intervertebral discs. The most common site of the lesion in this series was between the fourth and fifth lumbar vertebrae. Strain upon lifting was the most commonly reported precipitating factor.     

Low Back Pain in Men Receiving Workmen's Compensation

In Ontario, only about 10% of compensation patients with low back pain are disabled more than six weeks and hence tend to have chronic complaints. Six hundred and twenty-three such patients were studied to determine the distribution of diagnoses and to test the effectiveness of various programs of conservative therapy.Two hundred and thirteen patients were assigned in rotation to one of four treatments. The results were inconclusive. In 70% of these, the pain was due to intervertebral disc degeneration with added trauma.Two hundred and sixteen patients were assigned randomly to a treatment involving mild exercise, or one with vigorous exercise. Neither was found to be superior. In 76% of these, the pain was due to disc degeneration with added trauma.Using 194 patients, the results of treatment in the Compensation Board Rehabilitation Centre were compared with those obtained by treatment at home. Satisfactory improvement was achieved in 15 of 95 treated at home, and in 42 of 99 in the Centre. The failure of treatment in six of each 10 cases indicates that present-day methods of management of such patients are unsatisfactory.     

Vesical Dysfunction Due to Prolapsed Disc

Neural disturbance of micturition may occur as a result of a prolapsed intervertebral disc. Single nerve root lesions are unlikely to cause bladder dysfunction; a massive central protrusion producing total blockage of the vertebral canal or multiple disc lesions are more likely to cause disturbance of voiding. High lesions are more prone to cause severe bladder dysfunction. Vesical dysfunction may sometimes be present without the typical back and leg pain.Provided a gynaecological cause is excluded, any young or middle-aged woman developing incontinence and retention with a sterile urine must be fully investigated to exclude a disc lesion. Once the disc has been removed, bladder function will improve, but in some cases recovery will be slow. Rarely some patients have permanent bladder dysfunction following a disc operation.     

Barriers to mesenchymal stromal cells for low back pain

Intervertebral disc degeneration is the main cause of low back pain. In the past 20 years, the injection of mesenchymal stromal cells (MSCs) into the nucleus pulposus of the degenerative disc has become the main approach for the treatment of low back pain. Despite the progress made in this field, there are still many barriers to overcome. First, intervertebral disc is a highly complex load-bearing composite tissue composed of annulus fibrosus, nucleus pulposus and cartilaginous endplates. Any structural damage will change its overall biomechanical function, thereby causing progressive degeneration of the entire intervertebral disc. Therefore, MSC-based treatment strategies should not only target the degenerated nucleus pulposus but also include degenerated annulus fibrosus or cartilaginous endplates. Second, to date, there has been relatively little research on the basic biology of annulus fibrosus and cartilaginous endplates, although their pathological changes such as annular tears or fissures, Modic changes, or Schmorl's nodes are more commonly associated with low back pain. Given the high complexity of the structure and composition of the annulus fibrosus and cartilaginous endplates, it remains an open question whether any regeneration techniques are available to achieve their restorative regeneration. Finally, due to the harsh microenvironment of the degenerated intervertebral disc, the delivered MSCs die quickly. Taken together, current MSC-based regenerative medicine therapies to regenerate the entire disc complex by targeting the degenerated nucleus pulposus alone are unlikely to be successful.     

Increase of nerve growth factor levels in the human herniated intervertebral disc: can annular rupture trigger discogenic back pain?

Introduction

Nerve growth factor (NGF) has an important role in the generation of discogenic pain. We hypothesized that annular rupture is a trigger for discogenic pain through the action of NGF. In this study, the protein levels of NGF in discs from patients with disc herniation were examined and compared with those from discs of patients with other lumbar degenerative disc diseases.

Methods

Patients (n = 55) with lumbar degenerative disc disease treated by surgery were included. Nucleus pulposus tissue (or herniated disc tissue) was surgically removed and homogenized; protein levels were quantified using an enzyme-linked immunosorbent assay (ELISA) for NGF. Levels of NGF in the discs were compared between 1) patients with herniated discs (herniated group) and those with other lumbar degenerative disc diseases (non-herniated group), and 2) low-grade and high-grade degenerated discs. Patient’s symptoms were assessed using a visual analog scale (VAS) and the Oswestry disability index (ODI); the influence of NGF levels on pre- and post-operative symptoms was examined.

Results

Mean levels of NGF in discs of patients were significantly higher in herniated discs (83.4 pg/mg total protein) than those in non-herniated discs (68.4 pg/mg).No significant differences in levels of NGF were found between low-grade and high-grade degenerated discs. Multivariate analysis, adjusted for age and sex, also showed significant correlation between the presence of disc herniation and NGF levels, though no significant correlation was found between disc degeneration and NGF levels. In both herniated and non-herniated groups, pre-operative symptoms were not related to NGF levels. In the herniated group, post-operative lower extremity pain and low back pain (LBP) in motion were greater in patients with low levels of NGF; no significant differences were found in the non-herniated group.

Conclusions

This study reports that NGF increased in herniated discs, and may play an important role in the generation of discogenic pain. Analysis of patient symptoms revealed that pre-operative NGF levels were related to post-operative residual lower extremity pain and LBP in motion. The results suggest that NGF in the disc is related to pain generation, however, the impact of NGF on generation of LBP varies in individual patients.

Electronic supplementary material

The online version of this article (doi:10.1186/ar4674) contains supplementary material, which is available to authorized users.     

Increased IL-17 expression in degenerated human discs and increased production in cultured annulus cells exposed to IL-1ß and TNF-α

Abstract

IL-17 is expressed in a number of tissues including the intervertebral disc, where it exerts strong inflammatory properties. We evaluated IL-17 using immunolocalization in herniated and non-herniated human discs, IL-17 gene expression, and the production of IL-17 by annulus cells cultured in three dimensions in the presence of IL-1ß or TNF-α. There was no difference in the percentage of IL-17 positive cells in annulus or nucleus in herniated vs. non-herniated disc specimens. Molecular studies confirmed expression of IL-17 in disc tissue, with significantly increased expression in more degenerated discs; there was no difference in expression between herniated vs. non-herniated discs. Exposure to IL-1ß or TNF-α resulted in significantly greater production of IL-17. Our findings expand understanding of IL-17 production by disc cells and reveal the importance of non-canonical IL-17 production in the disc. Significantly greater expression of IL-17 in more degenerated discs adds to our understanding of the changes in disc cell function with advancing stages of disc degeneration.     

加巴喷丁与卡马西平治疗坐骨神经痛的疗效比较

目的 探讨加巴喷丁与卡马西平治疗坐骨神经痛的临床疗效.方法 选取2017年1月 ～2020年1月治疗的坐骨神经痛患者80例,随机分为观察组和对照组各40例,观察组给予加巴喷丁治疗,对照组给予卡马西平治疗.采用视觉模拟评分法(VAS)对两组患者治疗前、治疗4周后的疼痛程度进行评估,采用生活质量量表(QOL)评价两组患者治...     

Alterations in biochemical components of extracellular matrix in intervertebral disc herniation: role of MMP-2 and TIMP-2 in type II collagen loss

Alterations in the composition of intervertebral disc extracellular matrix, mainly collagen and proteoglycans, may cause changes in mechanical properties of the disc, leading to dysfunction, nerve root compression, and herniation with severe clinical manifestations. Matrix metalloproteinases may be involved in degradation by hydrolysing extracellular matrix components. Inhibitors of matrix metalloproteinases, in contrast, function in the maintenance of degradation control. In this study, we investigated: (i) whether the level of matrix degradation correlated with the duration of the symptomatic disease, (ii) roles of matrix metalloproteinase-2 (MMP-2) and tissue inhibitor of matrix metalloproteinases-2 (TIMP-2) in intervertebral disc degeneration. Nucleus pulposus of intervertebral discs were obtained from 22 patients and analysed for collagen and proteoglycan contents, and pro-MMP-2, TIMP-2 levels. Collagen content was determined as hydroxyproline and proteoglycan content was measured as glycosaminoglycans. The loss in matrix components did not correlate with the duration of the degenerative disc disease. Pro-MMP-2 levels were higher at early stages of the degenerative disc disease (r = -0.495, P < 0.05). TIMP-2 levels were similar in all samples. Pro-MMP-2 and TIMP-2 levels negatively correlated in herniated discs samples (r = -0.855, P < 0.01). Pro- MMP-2 levels negatively correlated with the collagen content in herniated disc material. Our findings may suggest a silent period of active disease prior to symptomatic outcome during which irreversible matrix loss occurs. Involvement of other proteolytic enzymes at different stages of the disease should also be investigated to help to control the degradation cascade at relatively early stages of disc degeneration before the clinical onset of disease.     

中药熏蒸联合推拿治疗腰椎间盘突出症的临床效果

目的：探讨中药熏蒸联合推拿治疗腰椎间盘突出症的临床效果。方法：选择2013 年12 月到2015 年1 月我院收治的112 例 腰椎间盘突出症患者为研究对象,根据治疗方法的不同分为研究组和对照组。对照组给予常规推拿治疗措施,研究组给予常规推 拿措施联合中药熏蒸治疗。比较两组患者的住院时间,下肢放射痛、麻木、腰痛的发生率及临床疗效。结果：研究组患者的住院时 间及下肢放射痛、麻木、腰痛的发生率均较对照组明显缩短或降低,其治疗总有效率为92.9%,显著高于对照组,均有统计学差异 (P＜0.05)。结论：中药熏蒸联合推拿方法治疗腰椎间盘突出症的临床效果优于单一推拿治疗措施,可有效改善患者的临床症状,缩 短疗程,提高治疗有效率,值得临床推广使用。     

Clinical Significance of Tumor Necrosis Factor-α Inhibitors in the Treatment of Sciatica: A Systematic Review and Meta-Analysis

Background and Objective

Currently, no satisfactory treatment is available for sciatica caused by herniated discs and/or spinal stenosis. The objective of this study is to assess the value of tumor necrosis factor (TNF)-α inhibitors in the treatment of sciatica.

Methods

Without language restrictions, we searched PubMed, OVID, EMBASE, the Web of Science, the Clinical Trials Registers, the Cochrane Central Register of Controlled Trials and the China Academic Library and Information System. We then performed a systematic review and meta-analysis on the enrolled trials that met the inclusion criteria.

Results

Nine prospective randomized controlled trials (RCTs) and two before-after controlled trials involving 531 patients met our inclusion criteria and were included in this study. Our systematic assessment and meta-analysis demonstrated that in terms of the natural course of the disease, compared with the control condition, TNF-α inhibitors neither significantly relieved lower back and leg pain (both p>0.05) nor enhanced the proportion of patients who felt overall satisfaction (global perceived effect (satisfaction)) or were able to return to work (return to work) (combined endpoint; p>0.05) at the short-term, medium-term and long-term follow-ups. In addition, compared with the control condition, TNF-α inhibitors could reduce the risk ratio (RR) of discectomy or radicular block (combined endpoint; RR = 0.51, 95% CI 0.26 to 1.00, p = 0.049) at medium-term follow-up, but did not decrease RR at the short-term (RR = 0.64, 95% CI 0.17 to 2.40, p = 0.508) and long-term follow-ups (RR = 0.64, 95% CI 0.40 to 1.03, p = 0.065).

Conclusion

The currently available evidence demonstrated that other than reducing the RR of discectomy or radicular block (combined endpoint) at medium-term follow-up, TNF-α inhibitors showed limited clinical value in the treatment of sciatica caused by herniated discs and/or spinal stenosis.