Northumbria Healthcare NHS Trust, Ashington, UK. To assess if a pain diary is useful in assessment and management of patients who undergo diagnostic nerve root block (NRB) for lumbar radicular pain. Prospective study. 23 patients who underwent diagnostic NRB for lumbar radicular pain were given a pain diary. They recorded their response to one of four options from Day 0 to Day 14 (good relief, partial satisfactory, partial unsatisfactory, and no relief of leg pain) and could also add additional comments. A Consultant Spinal Surgeon reviewed the diary with the patient at 6-week follow up appointment to formulate a management plan. Patient response, completion of the pain diary and final clinical outcome (surgical or non surgical treatment). The response rate was 91% (21/23). The pain diary was very useful in 43% (9/21), useful in 33% (7/21) and not useful in 24% (5/21) of patients in formulating further management. There was a tendency for patients with complex problems and poor response to add descriptive notes and comments (9/ 23). Patient compliance with pain diary was good and it has been valuable in making further management decisions. We found the pain diary to be a useful and inexpensive adjunct in the assessment of patients who underwent diagnostic NRB

Purpose of study and background

The use of NRB (Nerve Root Block) in radicular pain caused by stenosis is considered controversial in some centres, whereas its indication in radiculitis caused by disc herniation is widely accepted. Most studies evaluating NRB have combined disc herniation and stenosis pathologies in their inclusion criteria. This study explores the efficacy of NRB in different categories of stenosis: lateral recess, foraminal and combined.

Aims. This study was performed to explore the effect of melatonin on pyroptosis in nucleus pulposus cells (NPCs) and the underlying mechanism of that effect. Methods. This experiment included three patients diagnosed with lumbar disc herniation who failed conservative treatment. Nucleus pulposus tissue was isolated from these patients when they underwent surgical intervention, and primary NPCs were isolated and cultured. Western blotting, reverse transcription polymerase chain reaction, fluorescence staining, and other methods were used to detect changes in related signalling pathways and the ability of cells to resist pyroptosis. Results. Western blot analysis confirmed the expression of cleaved CASP-1 and melatonin receptor (MT-1A-R) in NPCs. The cultured NPCs were identified by detecting the expression of CD24, collagen type II, and aggrecan. After treatment with hydrogen peroxide, the pyroptosis-related proteins NLR family pyrin domain containing 3 (NLRP3), cleaved CASP-1, N-terminal fragment of gasdermin D (GSDMD-N), interleukin (IL)-18, and IL-1β in NPCs were upregulated, and the number of propidium iodide (PI)-positive cells was also increased, which was able to be alleviated by pretreatment with melatonin. The protective effect of melatonin on pyroptosis was blunted by both the melatonin receptor antagonist luzindole and the nuclear factor erythroid 2–related factor 2 (Nrf2) inhibitor ML385. In addition, the expression of the transcription factor Nrf2 was up- or downregulated when the melatonin receptor was activated or blocked by melatonin or luzindole, respectively. Conclusion. Melatonin protects NPCs against reactive oxygen species-induced pyroptosis by upregulating the transcription factor Nrf2 via melatonin receptors. Cite this article: Bone Joint Res 2023;12(3):202–211

To review our practice of requesting nerve root blocks, to see how effective our therapeutic blocks are and how many of our diagnostic blocks confirm clinical suspicion and help decision making. Retrospective cohort analysis. 120 fluoroscopically guided nerve root blocks were performed between 20/08/2008 and 29/12/2008. There were 100 patients who had pain diary data available, 42 males (mean age 52.02 range 20-76) 58 females (mean age 60.03, range 22-88). We recorded: clinical diagnosis, reason for block, result of block on a 10 point visual analogue pain diary on days 0, 2, 14 and at review. A successful block was defined as an improvement of at least 2 points. For the diagnostic blocks we also recorded whether the block result influenced surgical decision making. Block methods will be illustrated in diagram. Results will be displayed graphically and in text. 18 blocks were cervical (1 purely diagnostic, 6 therapeutic, and 10 mixed, 1 data unavailable). 71 blocks were lumbar (1 purely diagnostic, 28 purely therapeutic, and 37 mixed, 5 data unavailable). 28% of all blocks were successful immediately (2 unavailable data) and 22% at two weeks (1 unavailable data). By 3 months the success rate for therapeutic blocks was 26%. Of the blocks done for diagnostic reasons, 86% influenced a clinical decision at the next outpatient appointment. Our results justify the continuance of this service. Increased care should be taken that patients' outcome data is collected

Introduction. Thoracic wall surgery can cause severe pain and inhibition of coughing with effects. (1) Various local anaesthetic (LA) techniques have been tried successfully to mitigate the use of opioids alone. We believe this is the first time that a serratus plane block using an epidural catheter (SABER)has been studied in anterior spinal fusion (ASF) procedures. Our aim was to ascertain how it would affect ASF compared to gold standard posterior spinal fusion (PSF) surgery. Materials and Methods. We identified 43 patients from the years 2017 to 2019. 24 had ASF and 19 had PSF. Detailed data were collected on local anaesthetic infusion (LAI) SaBER, mean pain scores(MPS), morphine, chirocaine usage and hospital length of stay (HLOS). We divided the patients into 4 groups: Short PSF (SPSF), Long PSF (LPSF), Thoracic anterior fusion (TA) and Thoracolumbar anterior fusion (TLA) surgery. 4 patients in the SPSF and 4 in the LPSF group had LAI because they had a costoplasty. All patients in the anterior group had SaBER. Results. Mean morphine usage was higher in the ASF group. Mean LA usage was lowest in the TLA and highest in the LPSF group (see table). 12 and 24 hour MPS were lower in both anterior groups compared to posterior. Mean HLOS was similar in all groups. Conclusion. Despite painful costoplasties in the anterior group, LAI enabled lower MPS overall and similar HLOS between PSF and ASF groups. Consequently, ASF (with fewer fusion levels) can replace equivalent PSF with resultant less stiffness and increased mobility. Reduction in MPS may be further improved by investigating detailed protocols whereby boluses of LA are given in addition to LAI. This may lead to morphine sparing in the anterior group as has been seen in other studies on thoracic wall procedures. (2). For any figures or tables, please contact the authors directly

Background. There is growing evidence for an important role of central sensitization (CS) in the development and maintenance of chronic pain. This accounts for patients with chronic low back pain radiating to the leg (CLBPr) as well. Care as Usual (CaU) in these patients consists of diagnostic segmental nerve root blocks (dSNRB) followed by therapeutic interventions, i.e. a therapeutic segmental nerve root block (tSNRB) or pulsed radiofrequency (pRF). However, it is unknown if these procedures affect the amount of CS in these patients. Aim. The aim of the present study is to determine the alterations in the presentation of CS in CLBPr patients during care as usual. Hypothesis. A decrease in pain measured by NRS correlates with a decrease in CS (signs) in CLBPr patients undergoing SNRBs. Method/design. Case control study in 50 patients with CLBPr, for whom the physician is considering dSNRB and tSNRB or pRF, and 50 sex- and age-matched healthy controls. Following care as usual protocol, patients will receive dSNRB and tSNRB or pRF. Healthy control subjects will not undergo any procedure. The study has three to five visits, depending on the number of dSNRBs performed (max. 3). Evaluation. The bedside examination and questionnaires that are part of CaU will be extended with QST and CSI, NRS, PCS and PVAQ. The measurements will take place just before the dSNRBs, the tSNRBs or pRF and a follow-up four weeks after the intervention. Data collection will take 1 year. No conflict of interest. No funding obtained

Following the implementation of the Ionising Radiations (Medical Exposure) Regulations Act 2000 and recommendation from International Commission on Radiological Protection (ICRP), the establishment of diagnostic reference levels (DRLs) for all radiological examinations became mandatory. There are no recommended or published standards or national dosage guidelines in the UK of diagnostic reference levels available for fluoroscopy-guided diagnostic and therapeutic spinal procedures. The aim of this study is to establish reference dose area product (DAP) levels for the diagnostic spinal procedures requiring fluoroscopy as a basis for setting DRLs. All patient data consisted of diagnostic spinal procedures done in 2009 at Newcastle General Hospital under care of 4 spinal surgeons. Radiation data were collected on specific type of the procedure, DAP and screening time. Nerve root blocks, facet joint blocks and facet joint rhizolysis were included for data collection and analysis for this study. The third-quartile values were used to establish the DRLs. There were 387 nerve root blocks with a mean exposure per injection 171.3 cGycm. 2. (range, 3.0 to 2029.1; third quartile 209.4). Facet joint injections were 669 at a mean radiation dose 41.3 cGycm. 2. (range, 1.9 to 541.0; third quartile 48.9). In a total 430 facet joint rhizolysis, the mean exposure was 44.4 cGycm. 2. (range, 7.7 to 154.5; third quartile 58.4). The mean screening times were 36.7s (range, 0.4-281s; third quartile 41s) for nerve root blocks, mean 11.2s (range, 1.8-37s, third quartile 13.3s) for single facet joint block and mean 14.6s (range, 0.1-162s, third quartile 15.1s) for single facet rhizolysis. We found the third-quartile values for setting DRLs for single level nerve root block, single facet joint block and single facet joint rhizolysis to be 209.4, 48.9 and 58.4 cGycm. 2 . respectively. We recommend that all spinal units in the UK should establish their own local DRLs to help in establishing national dosage guidelines for fluoroscopy-guided diagnostic and also therapeutic spinal procedures

Introduction. Medical Exposure Directive of the European Commission, 97/43/Euratom recommended setting-up local national diagnostic reference levels (DRLs) for the most common radiological examinations in order to comply with the law and to maintain safe clinical practice. There are no guidelines for spinal diagnostic and therapeutic procedures. The aims of this study were to evaluate local radiation doses & screening times for diagnostic spinal blocks, to look at PACS image intensifier films for diagnostic representation and to assess the accuracy of data in IR(ME) document. Materials and Methods. Between 1/01/2009 and 15/07/2010, all spinal blocks done under care of three spinal surgeons (LB/NC/AAC) were reviewed. Images revisited on PACS for confirmation. We reviewed 229 patients (included single & two levels nerve root blocks, facet joint and lysis blocks). Data were collected with regard to radiation dose, screening times, third-quartile values used to establish DRLs, IR(ME) documentation and PACS fluoroscopic image documentation. Results. Third quartile single level NRB DAP (Dose area product) was 111.5 cGyCm2. Single level NRB screening time was mean-0.13, third quartile-0.2 min. Nerve specific dosimetry included L5 nerve (0.2 min; 119cGyCm2) and S1 nerve (0.2 min; 118.7cGyCm2). Mean ‘Click: Block ratio’ (last click for PACS/Block) was 22.4 (SD=7.05, range 10 to 48). Local fluoroscopic documentation was 87.2%. Conclusions. There are no national standards in radiation dosimetry for diagnostic spinal blocks. We recommend that all spinal units in the UK should evaluate their own DRLs to help establish national guidelines for fluoroscopy-guided spinal procedures. Representative fluoroscopic image documentation on PACS was 87% locally. It is a joint responsibility of radiographer & operating surgeon to make it 100% to reduce medicolegal risks

Background. Signalling by growth differentiation factor 6 (GDF6/BMP13) has been implicated in the development and maintenance of healthy NP cell phenotypes and GDF6 mutations are associated with defective vertebral segmentation in Klippel-Feil syndrome. GDF6 may thus represent a promising biologic for treatment of IVD degeneration. This study aimed to investigate the effect of GDF6 in human NP cells and critical signal transduction pathways involved. Methods. BMP receptor expression profile of non-degenerate and degenerate human NP cells was determined through western blot, immunofluorescence and qPCR. Phosphorylation statuses of Smad1/5/9 and non-canonical p38 MAPK and Erk1/2 were assessed in the presence/absence of pathway blockers. NP marker and matrix degrading enzyme gene expression was determined by qPCR following GDF6 stimulation. Glycosaminoglycan and collagen production were assessed through DMMB-assay and histochemical staining. Results. NP cells expressed all GDF6 receptor subunits, with receptor subunits BMPR-1A and BMPR2 displaying the highest expression and highest binding affinity. GDF6 stimulation significantly upregulated the expression of NP specific marker genes but had no significant effect on the expression of matrix degrading enzymes. Total glycosaminoglycan and collagen production was also significantly increased following GDF6 stimulation. Smad1/5/9, p38 MAPK and Erk1/2 pathways were phosphorylated following GDF6 stimulation and could be effectively blocked. Conclusions. These findings enhance our understanding of both the effects of GDF6 in NP cells and the mechanisms of GDF6 signal transduction that are critical to promote NP phenotype and cellular function. This knowledge is important for the effective use of GDF6 as a therapeutic molecule for treatment of IVD degeneration. Conflicts of interest. No conflicts of interest. Sources of funding. We would like to acknowledge UKRMP Acellular Hub, MRC, NIHR Musculoskeletal BRU and The Rosetrees Trust for funding this research

Aims

In this investigation, we administered oxidative stress to nucleus pulposus cells (NPCs), recognized DNA-damage-inducible transcript 4 (DDIT4) as a component in intervertebral disc degeneration (IVDD), and devised a hydrogel capable of conveying small interfering RNA (siRNA) to IVDD.

Aims

People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians’ views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial).

To analyse if patients with pain improvement following a nerve root block had better outcomes following lumbar microdiscectomy. Fifty-six patients who had a lumbar microdiscectomy were retrospectively followed up to 1 year. All patients had a selective nerve root block (SNRB) as a primary treatment or diagnostic procedure. VAS pain scores were measured daily for 1 week following injection. Patients were grouped into responders and non-responders at 1 week. The 2 groups of patients were followed at 1 year following a lumbar microdiscetomy (LMD). A total of 118 patients had SNRB over a period of 3 years. Of the 56 patients studied retrospectively, 52% and 36% of patients had a VAS score improvement of more than 2 points at 4 days and 1 week respectively. At 1 year post op, 85% of patients had better outcomes in the responder group compared to 74% in the non responder group. Although there was a difference this was not statistically significant. Improvement with SNRB is not a positive predictor of good response with surgery. The ability to evaluate the effect of diagnostic or therapeutic blocks on surgical outcomes is limited by a lack of randomized studies and wide-ranging discrepancies with regard to injection techniques, surgical technique, and outcome measures. More research is needed to determine if diagnostic screening blocks can improve surgical outcomes

To analyse if patients with pain improvement following a nerve root block had better outcomes following lumbar microdiscectomy. Fifty-six patients who had a lumbar microdiscectomy were retrospectively followed up to 1 year. All patients had a selective nerve root block (SNRB) as a primary treatment or diagnostic procedure. VAS pain scores were measured daily for 1 week following injection. Patients were grouped into responders and non-responders at 1 week. The 2 groups of patients were followed at 1 year following a lumbar microdiscetomy (LMD). A total of 118 patients had SNRB over a period of 3 years. Of the 56 patients studied retrospectively, 52% and 36% of patients had a VAS score improvement of more than 2 points at 4 days and 1 week respectively. At 1 year post op, 85% of patients had better outcomes in the responder group compared to 74% in the non responder group. Although there was a difference this was not statistically significant. Improvement with SNRB is not a positive predictor of good response with surgery. The ability to evaluate the effect of diagnostic or therapeutic blocks on surgical outcomes is limited by a lack of randomized studies and wide-ranging discrepancies with regard to injection techniques, surgical technique, and outcome measures. More research is needed to determine if diagnostic screening blocks can improve surgical outcomes

The use of nerve root blocks is common in the management of radicular pain due to lumbar disc prolapse. However, most papers reporting their use do not necessarily specify the position or level at which the needle is positioned with respect to the level of pathology. We therefore set out to investigate this. We performed a survey of medical practitioners across the UK with an interest or involvement in the management of radicular pain secondary to lumbar disc prolapse The survey depicted the clinical scenario of a patient with radicular pain from an L4/5 disc prolapse and a number of questions were asked in relation to the use of nerve root blocks. Questionnaires were sent to 319 practitioners. We received 153 responses of which, 120 (37.6%) were sufficiently complete to be analysed. Of those who responded, 83% used a combination of local anaesthetic and steroids together with or without contrast. There were variations across the respondents in terms of the level injected with 22.5% injecting at the level of the L4/5 foramen, while 45% injected at the level of the L5/1 foramen. Differences were also noted when respondents were subgrouped according to their speciality. Of those who worked in pain management, 34.1% injected at the L4/5 foramen while 31.8% injected at the L5/1 foramen. For spine surgeons the respective figures were 20.5% and 43.2% and for radiologists 9.4% and 65.6%. In the treatment of radicular leg pain, there are apparent variations in the use and positioning of root blocks for a given level of disc pathology. This suggests that caution is necessary when considering the validity of published studies on the use of root blocks relative to an individual clinician's practice

Aims

To investigate the correlations among cytokines and regulatory T cells (T-regs) in ankylosing spondylitis (AS) patients, and their changes after anti-tumour necrosis factor-α (TNF-α) treatment.

Aims

We compared decompression alone to decompression with fusion surgery for lumbar spinal stenosis, with or without degenerative spondylolisthesis (DS). The aim was to evaluate if five-year outcomes differed between the groups. The two-year results from the same trial revealed no differences.

Aims

The development of lumbar lordosis has been traditionally examined using angular measurements of the spine to reflect its shape. While studies agree regarding the increase in the angles during growth, the growth rate is understudied, and sexual dimorphism is debated. In this study, we used a novel method to estimate the shape of the lumbar curve (LC) using the landmark-based geometric morphometric method to explore changes in LC during growth, examine the effect of size and sex on LC shape, and examine the associations between angular measurements and shape.

Aims

CRP is an acute-phase protein that is used as a biomarker to follow severity and progression in infectious and inflammatory diseases. Its pathophysiological mechanisms of action are still poorly defined. CRP in its pentameric form exhibits weak anti-inflammatory activity. The monomeric isoform (mCRP) exerts potent proinflammatory properties in chondrocytes, endothelial cells, and leucocytes. No data exist regarding mCRP effects in human intervertebral disc (IVD) cells. This work aimed to verify the pathophysiological relevance of mCRP in the aetiology and/or progression of IVD degeneration.

Background. Acute lumbar radiculopathy is a very painful condition sometimes requiring admission for strong analgesia. Purpose. To evaluate the efficacy of distal nerve root blocks as an outpatient procedure for immediate pain relief. Methods. Local anaesthetic was injected in the distal nerve root areas of the leg and foot in the clinic in patients with lumbar radiculopathy who consented to the procedure. Results. There were 29 patients, 18 females and 11 males, aged 25 to 76 years. 13 patients had acute lumbar disc prolapse, 11 had lumbar canal stenosis, 2 had annular tears and one a facet joint cyst. The VAS pain scores ranged from 3 to 11 (patient's description), with an average VAS score of 7.5. The improvement in VAS scores was between 2 and 9 with average improvement of 6. 19 patients had associated back pain which improved in 14. Walking improved in all 29 patients. Pain relief was immediate in all patients. This lasted from 30 min to 11 days with one patient having no recurrence. 27 patients had at least 24 hours pain relief. All patients could be sent home immediately after the procedure. 12 patients had recent onset of foot weakness which improved one MRC grade immediately after the injection. The analgesic effect was most significant in acute disc prolapse. There were no complications. Conclusion. This technique is simple and would be valuable in the acute setting to provide immediate pain relief allowing immediate discharge from accident and emergency. Conflicts of interest: None. Sources of funding: None

Background. NICE guidance suggests that caudal epidural injections of steroid and local anaesthetic may be considered for acute and severe sciatica, however studies have demonstrated limited long-term benefit and impact on future surgery. This study aimed to investigate the use of caudal epidural injections in a district general hospital setting and the rate of subsequent operation. Methods. All patients undergoing caudal epidural injection between 1. st. January and 30. th. June 2015 were included. Records were reviewed to obtain diagnosis, pre- and post-epidural clinical findings, prior interventions, and subsequent operations. Results. A total of 141 patients underwent a caudal epidural, with a median age of 63 (18 – 90). 37 patients went on to surgical intervention within 3 years, resulting in a conversion rate of 26.1%. Amongst those not requiring surgery, 59 (56.19%) had disc herniation, 42 (40%) stenosis, 4 spondylolisthesis, and 1 a facet cyst. Pre-operatively 63.81% reported back pain and 93.33% sciatica. 39.05% of patients had sensorimotor changes. Post-operatively, 27.62% reported an improvement in their back pain, compared to 62.86% reporting improved leg pain. 36.59% of those with sensorimotor changes reported improvement. 32 later had a further caudal epidural or foraminal block, and 25 had facet and sacroiliac joint injections. Amongst those requiring surgery, 21 (56.76%) had disc herniation, 15 (40.54%) stenosis, and 1 spondylolisthesis (2.7%). Conclusion. In our series, approximately three quarters of patients undergoing caudal epidural injection did not subsequently require surgery. Lumbosacral radicular symptoms improved in two thirds, however the epidural was less effective at treating back pain. No conflicts of interest. No funding obtained