Herbal Medicine for Low Back Pain: A Cochrane Review

Study Design. Systematic review of randomized controlled trials (RCTs). Objectives. To determine the effectiveness of herbal medicine for nonspecific low back pain (LBP). Summary of Background Data. Many people with chronic LBP use complementary and alternative medicine (CAM), visit CAM practitioners, or both. Several herbal medicines have been purported for use in treating people with LBP. This is an update of a Cochrane Review first published in 2006. Methods. We searched numerous electronic databases up to September 2014; checked reference lists in review articles, guidelines and retrieved trials; and personally contacted individuals with expertise in this area. We included RCTs examining adults (over 18 years of age) suffering from acute, sub-acute, or chronic nonspecific LBP. The interventions were herbal medicines that we defined as plants used for medicinal purposes in any form. Primary outcome measures were pain and function. Two review authors assessed risk of bias, GRADE criteria (GRADE 2004), and CONSORT compliance and a random subset were compared with assessments by a third individual. Two review authors assessed clinical relevance and resolved any disagreements by consensus. Results. Fourteen RCTs (2050 participants) were included. Capsicum frutescens (cayenne) reduces pain more than placebo. Although Harpagophytum procumbens (devil's claw), Salix alba (white willow bark), Symphytum officinale L. (comfrey), Solidago chilensis (Brazilian arnica), and lavender essential oil also seem to reduce pain more than placebo, evidence for these substances was of moderate quality at best. No significant adverse events were noted within the included trials. Conclusions. Additional well-designed large trials are needed to test these herbal medicines against standard treatments. In general, the completeness of reporting in these trials was poor. Trialists should refer to the CONSORT statement extension for reporting trials of herbal medicine interventions. Level of Evidence: N/A

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Glycosaminoglycan Chemical Exchange Saturation Transfer of Lumbar Intervertebral Discs in Healthy Volunteers

Study Design. Evaluation of a new quantitative imaging technique in a prospective study design. Objective. To assess glycosaminoglycan (GAG) content of lumbar intervertebral discs (IVDs) in healthy volunteers with chemical exchange saturation transfer (CEST). Summary of Background Data. Biochemical alterations of lumbar discs are present before the appearance of morphological changes. GAG loss plays a central role in these degenerative processes. Methods. Lumbar intervertebral discs of healthy controls (26 women, 22 men; mean age 31 ± 8 years; range: 21–49 years) without lumbar back pain were examined at a 3 Tesla magnetic resonance imaging (MRI) scanner in this prospective study. None of the participants were overweight or had previous surgery of the lumbar spine. The MRI protocol included standard morphological, sagittal and transversal T2-weighted (T2w) images to assess Pfirrmann score and to detect disc disorders according to the Combined Task Force classification of five lumbar IVDs (L1 to S1). A prototype glycosaminoglycan chemical exchange saturation transfer (gagCEST) sequence was applied to measure GAG content of the nucleus pulposus (NP) and annulus fibrosus (AF) by identifying the magnetization transfer asymmetry ratio (MTRasym) in a region-of-interest analysis. Morphological and biochemical imaging analysis were statistically tested for quantitative differences between different grades of IVD degeneration and disc disorders. Results. gagCEST values of NP demonstrated a significant negative correlation with morphological Pfirrmann score (r = −0.562; P < 0.0001). The MTRasym values were higher in non-degenerative lumbar IVDs (Pfirrmann 1–2) compared with degenerative lumbar discs (Pfirrmann 3–5; 2.92% ± 1.42% vs. 0.78% ± 1.38%; P < 0.0001). The MTRasym values of NP were significantly higher in normal appearing discs compared with herniated IVDs (2.83% ± 1.52% vs. 1.55% ± 1.61%; P < 0.0001). We found a significant negative correlation between gagCEST values and the graduation of disc herniation (r = −0.372; P < 0.0001). Conclusion. Biochemical imaging with gagCEST distinguished morphologically degenerative from non-degenerative lumbar IVDs (in NP and AF) of healthy volunteers at a clinical 3T-MRI system. The depletion of GAG content in degenerative lumbar discs correlated significantly with the morphological disc classification. We could demonstrate that disc disorders, such as protrusion and extrusion, were accompanied by lower GAG content. Level of Evidence: 2

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Is There an Association Between Radiological Severity of Lumbar Spinal Stenosis and Disability, Pain, or Surgical Outcome?: A Multicenter Observational Study

Study Design. Observational multicenter study. Objective. To evaluate if the severity of lumbar spinal stenosis (LSS) on magnetic resonance imaging (MRI) correlates with preoperative disability, pain, or surgical outcomes. Summary of Background Data. Surgeons use the morphological appearance of LSS on MRI for clinical decision making. However, the associations between radiological severity of LSS and disability, pain, or surgical outcomes remain unclear. Methods. Evaluation of severity of LSS on preoperative MRI according to the Schizas morphological classification. Patient and treatment data were retrieved from the Norwegian Registry for Spine Surgery. Preopertaive outcome measures were Oswestry disability index (ODI) and numeric rating scale (NRS) scores for back and leg pain. Postopertive outcome measures were ODI and NRS scores for back and leg pain at 1 year, changes in ODI and NRS scores after treatment, duration of surgery, length of hospital stay, and perioperative complications. Results. Of 202 patients included, 7 were found to have mild stenosis, 38 had moderate stenosis, 108 had severe stenosis, and 49 had extreme stenosis. The radiological severity of LSS was not linked to preoperative ODI (P = 0.089), NRS back pain (P = 0.273), or NRS leg pain (P = 0.282) scores. There were no differences in ODI (P = 0.933), NRS back pain (P = 0.652), or NRS leg pain (P = 0.912) scores after 1 year. The radiological severity of stenosis was not associated with change in ODI (P = 0.494), NRS back pain (P = 0.235), NRS leg pain (P = 0.790), duration of surgery (P = 0.661), length of hospital stay (P = 0.739), or perioperative complication rates (P = 0.467). Conclusion. Among patients who underwent decompressive surgery for LSS, radiological severity of stenosis was not associated with preoperative disability and pain, or clinical outcomes 1 year after surgery. In this patient group, the radiological severity of LSS has no clear clinical correlation and should therefore not be overemphasized in clinical decision making. Level of Evidence: 2

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Mechanism of Action of Spinal Mobilizations: A Systematic Review

Study design. Systematic review. Objective. To review the evidence regarding the mechanism of action of mobilizations. Summary of background data. Spinal mobilizations—low velocity passive oscillatory movements—reduce spinal pain in some patient subgroups. Identifying patients likely to respond remains a challenge since mobilizations’ mechanism(s) of action are unclear. Methods. Medline, Web of Science, Cinahl, Embase, and Scopus databases were searched for relevant studies. Reference lists of included studies were hand searched. Studies were included if the intervention was passive spinal mobilizations, participants were symptomatic, and outcomes evaluated possible mechanisms of action. Methodological quality was independently assessed by two assessors using a modified Cochrane Back Review Group tool. Results. Twenty-four studies were included in the review. Four were classified high risk, 14 moderate risk, and four low risk of bias. Commonest methodological limitations were lack of participant blinding, adequate randomization and allocation concealment, and sample size calculation. Evidence suggests that spinal mobilizations cause neurophysiological effects resulting in hypoalgesia (local and/or distal to mobilization site), sympathoexcitation, and improved muscle function. Mobilizations have no effect on temperature pain threshold. Three of four studies reported reduction in spinal stiffness, heterogeneous in location and timing. There is limited evidence (one study in each case) to suggest that mobilizations produce increased nociceptive flexion reflex threshold, improved posture, decreased concentration of substance P in saliva, and improved sway index measured in cervical extension. Evidence does not support an effect on segmental vertebral movement. Two studies investigated correlations between hypoalgesia and mechanism: one found a correlation with sympathoexcitatory changes, whereas the other found no correlation with change in stiffness. Conclusion. These findings suggest involvement of an endogenous pain inhibition system mediated by the central nervous system, although this is yet to be investigated directly. There is limited evidence regarding other possible mechanisms. Level of Evidence: 3

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Minimally Invasive Versus Open Laminectomy for Lumbar Stenosis: A Systematic Review and Meta-Analysis

Study Design. Systematic review with meta-analysis. Objective. To assess the relative merits of minimally invasive unilateral laminectomy for bilateral decompression (ULBD) versus open laminectomy, a systematic review and meta-analysis of all available evidence was performed. Summary of Background Data. Lumbar spinal stenosis is one of the most common pathologies in the increasingly elderly population that results in claudication, back and leg pain, and disability. The conventional approach for decompression is open laminectomy. In recent years, there has been a surge in microendoscopic procedures, which aim to minimize invasiveness. Despite the increasing use of these minimally invasive techniques, few studies have directly compared the safety, efficacy, and outcomes of these procedures with conventional laminectomy. There is a lack of robust clinical evidence, with most reports limited to single-center, inadequately powered, noncomparative studies. Methods. Relevant articles were identified from six electronic databases. Predefined endpoints were extracted and meta-analyzed from the identified studies. Results. Satisfaction rates were significantly higher in the minimally invasive group (84% vs. 75.4%; P = 0.03), whereas back pain Visual Analog Scale scores were lower (P < 0.00001). Minimally invasive laminectomy operative duration was 11 minutes longer than the open approach (P = 0.001), however this may not have clinical significance. However, there was less blood loss (P < 0.00001) and shorter hospital stay (2.1 days; P < 0.0001). Dural injuries and cerebrospinal fluid leaks were comparable, but reoperation rates were lower in the minimally invasive cohort (1.6% vs. 5.8%; P = 0.02); however this was not significant when only randomized evidence was considered. Conclusion. The pooled evidence suggests ULBD may be associated with less blood loss and shorter stay, with similar complication profiles to the open approach. These findings warrant verification in large prospective registries and randomized trials. Level of Evidence: 1

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Complications and Rates of Subsequent Lumbar Surgery Following Lumbar Total Disc Arthroplasty and Lumbar Fusion

Study Design. Retrospective analysis. Objective. To examine complications and rates of subsequent surgery following lumbar spinal fusion (LF) and lumbar total disc arthroplasty (TDA) at up to 5-year follow-up. Summary of Background Data. LF is commonly used in the management of degenerative disc disease causing pain refractory to nonoperative management. Lumbar TDA was developed as an alternative to fusion with the theoretical advantage of reducing rates of adjacent segment pathology and reoperation. Most prior reports comparing these 2 interventions have come from industry-sponsored investigational device exemption trials and no large-scale administrative database comparisons exist. Methods. The California Office of Statewide Health Planning and Development discharge database was queried for patients aged 18 to 65 years undergoing lumbar TDA and LF for degenerative disc disease from 2004 to 2010. Patient characteristics were collected, and rates of complications and readmission were identified. Rates of repeat lumbar surgery were calculated at 90-day and 1-, 3-, and 5-year follow-up intervals. Results. A total of 52,877 patients met the inclusion criteria (LF = 50,462, TDA = 2415). Wound infections were more common following LF than TDA (1.03% vs. 0.25%, P < 0.001). Rates of subsequent lumbar surgery at 90-day and 1-year follow-up were lower with lumbar TDA than LF (90-day—TDA: 2.94% vs. LF: 4.01%, P = 0.007; 1-yr—TDA: 3.46% vs. LF: 4.78%, P = 0.009). However, there were no differences in rates of subsequent lumbar surgery between the 2 groups at 3-year and 5-year follow-up. Conclusion. Lumbar TDA was associated with fewer early reoperations, though beyond 1 year, rates of reoperation were similar. Lumbar TDA may be associated with fewer acute infections, though this may be approach related and unrelated to the device itself. Level of Evidence: 3

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Worms in the emergency department

A 25 year old woman presented to our emergency department with abdominal pain, vomiting, and diarrhoea. Physical examination showed abdominal tenderness. Blood test results were normal. Abdominal...

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