Objective

The STarT Back Screening Tool (STarT) is a 9-item patient self-report questionnaire that classifies low back pain patients into low, medium or high risk of poor prognosis. When assessed by GPs, these subgroups can be used to triage patients into different evidence-based treatment pathways. The objective of this study was to translate the English version of STarT into Danish (STarT-dk) and test its discriminative validity.

Purpose

To describe the frequency of different patterns of pain response and their association with outcomes (prognosis) and MRI findings in patients experiencing sciatica.

Background: The dermatomal drawings used in clinical practice are based on questionable experiments performed in the 1930s. Though widely used in the clinical practice to identify the level of nerve root irritation, this may not be a reliable practise.

Purpose: To identify the pain distribution and overlap of single level L4, L5 and S1nerve root irritation.

Methods: 187 patients with radicular pain to or below the knee made a precise drawing of their pain distribution and then underwent a MRI scan. Only patients identified as having a single level disc herniation were included in this study. Using computer software, the pain distribution of all people who had the same level nerve root irritation was made by layering their pain drawings. The darkest parts of these compound drawings was where most patients experienced pain.

Results: 89 patients were excluded due to tumour, depression or disc lesions on several levels. 98 patients with single level disc herniation were included.

There was wide overlap in the pain from each nerve root level, and these areas were much wider than shown on dermatome charts. In general, L4 nerve root pain tended to be anterior on the leg, L5 and S1 nerve root pain was on the posterior leg, with L5 root pain tending to be more lateral.

Conclusion: Pain distribution from the L4, L5, S1 nerve roots is not concordant with the sensory distribution of common dermatome charts. This might be due to the methods by which these dermatomes were constructed, or because sciatica is a complex pain experience.

Background: Generalised joint hypermobility (GJH) has a prevalence of approximately 5% in the general population. There might be an association between GHJ and some low back pain. The Beighton Criteria are 9 tests that are widely used to diagnose GJH but it is time-consuming to perform all nine tests.

Purpose: To evaluate which of the nine Beighton tests is the most accurate as a screening test for GHJ. To investigate the relationship between hypermobility and age, gender, and ethnicity.

Methods: From the last 10 years archives at the Back Centre Funen 17,117 patient records were examined. All nine Beighton tests had been performed in 4,062 patients. Data on the nine Beighton tests and age, gender, and ethnicity were extracted.

Results: There was a selection bias in this clinical sample, as the prevalence of GJH was 14.6%. All tests showed an overall accuracy of > 85.2 % as single-item screening tests for GJH in low back pain patients. Extension of the dominant elbow > 10o was the most accurate screening test with an overall accuracy of 93.9 %, sensitivity 76.6 % specificity 96.9 %. There was a higher prevalence of GJH in women (22.8%) than men (3.8%) and in young patients (28.0%) than in older patients (2.5%). No difference in the prevalence of GJH was observed between the patients with Danish ethnicity and non-Danish ethnicity.

Conclusion: Extension of the dominant elbow > 10o was the single most accurate of the nine Beighton tests as a screening test for GJH in patients with low back pain.

Introduction: Modic changes have recently been identified as a pain giving pathoanatomical diagnosis for a considerable percentage (20–30 %) of Low Back Pain (LBP) patients. The causes of these Modic changes have not been determined conclusively.

The aim was to evaluate a possible effect of antibiotic treatment in an uncontrolled group of patients with LBP and Modic changes.

Methods: A cohort of patients (n=32) participated in this study. The patients had previous sciatic mostly from lumbar disc herniation, all were treated conservatively. At the 14 month follow-up, 43 of the patients had Modic changes, six of whom did not suffer from LBP, five declined participation. The treatment consisted of amoxicillin-clavulanate (500 mg/125 mg) (Spektramox ®) three times a day for 90 days.

Results: Twenty-nine patients completed the treatment, of which 15 (52 %) reported that they were much better or cured, 7 (24 %) experienced moderate improvement, and 7 (24 %) remained unchanged. None reported a worsening of symptoms. At the end of treatment and at long term follow-up (mean 10.8 months) there was both a clinically and statistically significant (p< 0.001) improvement found in all outcome parameters, namely; general health, disease and patient specific function, pain in the lumbar area, and number of days with pain.

Discussion: The clinical effect of antibiotic treatment was profound in a group of patients suffering from persistent low back pain after experiencing a disc herniation. Our results support the theory that bacterial infection could play a role in LBP with Modic changes.

The study was founded by The Regional Institute of Health Sciences Research

Background: There is a need for identifying specific subgroups of LBP, Modic changes might be one of these subgroups. The aim is to describe the relationship between a previous herniated disc and the following Modic changes.

Methods: 181 patients with radicular pain below the knee, leg pain ≥ 3, duration of leg pain between 2 and 52 weeks, and age between 18 and 65 years were included. The patients were randomized into one of two active conservative treatment regimes lasting eight weeks. All included patients were scanned at baseline and again at 14 months follow-up. All MRI evaluation was carried out by the same experienced radiologist using a validated evaluation protocol.

Results: The prevalence of Modic changes type 1 increased more than 3 fold from 9 % at baseline to 29 % at follow-up; type 2 was respectively 14 % and 13 %. In patients with Modic changes at baseline, extremely few reduced in size or disappeared, on the contrary new type 1 changes developed after the herniation. In patients with a normal disc, 0 % developed Modic changes at follow-up, whereas in those with extrusions and sequestrations 56–63%. There exist a strong association between Modic changes and LBP, 67 % of those with Modic changes had LBP compared to 21 % of the patients without, OR 6.1, (p< 0.0001).

Discussion: A lumbar disc herniation is a strong risk factor for developing Modic changes (especially type 1) during the following year. Furthermore, Modic changes are strongly associated with LBP.

Background: Reviews have showed none or little efficacy of passive conservative treatment modalities for patients with sciatica, reviews on surgery are conflicting. Cohort studies have shown high efficacy of active conservative treatment for patients with sciatica.

The aim was to evaluate the efficacy of two active conservative treatment programs to patients with severe sciatica.

Methods: The study was a prospective single-blind randomized clinical controlled trial of 181 consecutive patients with radicular pain below the knee. The patients were examined at baseline, 8 weeks later at post treatment follow-up, and at one year follow-up.

In both groups treatment consisted of thorough Information concerning anatomy, pathogenesis, how discs heal without surgery, and Advice and encouragement to stay as active as possible, and optional medication. Then either Symptom guided exercises or Sham exercises.

Results: All patients experienced a highly significant and clinically important improvement in global assessment, functional status, pain, vocational status, and clinical findings. The Symptom guided exercises + Information + Advice to stay active group (SYMIA) was significantly superior to the Sham exercises + Information + Advice to stay active group (SHAMIA) with regards to global assessment, clinical findings, sick leave and vocational status both at end of treatment and one year follow-up. There was a borderline significant difference in leg pain at end of treatment, and no difference was found in RMQ and EQ-5D.

Conclusion: Patients who had symptoms and clinical findings which would qualify them for surgery in most hospitals improved greatly with active conservative treatment. Although the patients had greater faith in the SHAMIA before treatment, the SYMIA treatment was superior in most outcomes.

Background: In studies using MRI to describe disc changes over time, herniations have been reported to reduce in 35–100% of cases.

The aim of this study was to describe the development of disc related MRI-findings in patients with sciatica treated conservatively using a validated evaluation protocol.

Methods: Included in this prospective intervention study were; 181 patients with radicular pain below the knee, leg pain ≥ 3, duration of leg pain between 2 and 52 weeks. The patients were randomized into one of two active conservative treatment regimes lasting eight weeks. All included patients were scanned at baseline and again at 14 months follow-up. MRI evaluation was performed, using a validated evaluation protocol.

Results: In 139 (90%) of 154 patients included (median age 46 years) was it possible to identify a symptomatic disc level: 33 bulging discs, 52 focal protrusions, 10 broad-based protrusions, 36 extrusions, and 8 sequestrations.

Three percent of bulges and 38% of focal protrusions improved, whereas 75 – 100% of the more substantial herniations, i.e. broad-based, extrusions, and sequestrations improved (p< 0.0001). Improvement over time for nerve root compromise was seen in 60% of the cases. Disc signal, disc height, and HIZ remained unchanged in 63–73%. Treatment and age groups did not show any differences. However, gender differences were found in relation to baseline findings and development over time.

Conclusion: In general, symptomatic discs showed good MRI-prognosis, especially for those extruded. This study implies that active conservative treatment does not interfere with disc morphology as seen on MRI.