Shoulder pain due to cervical radiculopathy: an underestimated long-term complication of herpes zoster virus reactivation?

Purpose To evaluate if herpes zoster virus (HZV) reactivation may be considered in the aetiology of cervical radiculopathy. Methods The study group was composed of 110 patients (52 M-58F;mean age ± SD:46.5 ± 6.12; range:40-73) with a clinical diagnosis of cervical radiculopathy. Patients with signs of chronic damage on neurophysiological studies were submitted to an X-ray and to an MRI of the cervical spine in order to clarify the cause of the cervical radiculopathy and were investigated for a possible reactivation of HZV; HZV reactivation was considered as “recent” or “antique” if it occurs within or after 24 months from the onset of symptoms, respectively. Data were submitted to statistics. Results Thirty-eight patients (34,5%,16 M-22F) had a history of HZV reactivation: four (2 M-2F) were “recent” and 34 (14 M-20F) were “antique”. In 68 of 110 participants (61,8%,30 M-38F), pathological signs on X-ray and/or MRI of the cervical spine appeared; in the remaining 42 (38,2%,22 M-20F) X-ray and MRI resulted as negative. Among patients with HZV reactivation, seven (18,4%) had a “positive” X-ray-MRI while in 31 (81,6%) the instrumental exams were considered as negative. The prevalence of “antique” HZV reactivations was statistically greater in the group of patients with no pathological signs on X-ray/MRI of the cervical spine with respect to the group with a pathological instrumental exam (p < 0.01). Conclusions It may be useful to investigate the presence of a positive history of HZV reactivation and to consider it as a long-term complication of a cervical root inflammation especially in patients in which X-ray and MRI of the cervical spine did not show pathological findings

Comparison of standard fusion with a "topping off" system in lumbar spine surgery: a protocol for a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Fusion of lumbar spine segments is a well-established therapy for many pathologies. The procedure changes the biomechanics of the spine. Initial clinical benefits may be outweighed by ensuing damage to the adjacent segments. Various surgical devices and techniques have been developed to prevent this deterioration. "Topping off" systems combine rigid fusion with a flexible pedicle screw system to prevent adjacent segment disease (ASD). To date, there is no convincing evidence that these devices provide any patient benefits.</p> <p>Methods/Design</p> <p>The study is designed as a randomized, therapy-controlled trial in a clinical care setting at a university hospital. Patients presenting to the outpatient clinic with degenerative disc disease or spondylolisthesis will be assessed against study inclusion and exclusion criteria. After randomization, the control group will undergo conventional fusion. The intervention group will undergo fusion with a supplemental flexible pedicle screw system to protect the adjacent segment ("topping off").</p> <p>Follow-up examination will take place immediately after treatment during hospital stay, after 6 weeks, and then after 6, 12, 24 and 36 months. Subsequently, ongoing assessments will be performed annually.</p> <p>Outcome measurements will include quality of life and pain assessments using questionnaires (SF-36™, ODI, COMI). In addition, clinical and radiologic ASD, work-related disability, and duration of work disability will be assessed. Inpatient and 6-month mortality, surgery-related data (e.g., intraoperative complications, blood loss, length of incision, surgical duration), postoperative complications, adverse events, and serious adverse events will be documented and monitored throughout the study. Cost-effectiveness analysis will also be provided.</p> <p>Discussion</p> <p>New hybrid systems might improve the outcome of lumbar spine fusion. To date, there is no convincing published data on effectiveness or safety of these topping off systems. High quality data is required to evaluate the benefits and drawbacks of topping off devices. If only because these devices are quite expensive compared to conventional fusion implants, nonessential use should be avoided. In fact, these high costs necessitate efforts by health care providers to evaluate the effects of these implants. Randomized clinical trials are highly recommended to evaluate the benefits or harm to the patient.</p> <p>Trial Registration</p> <p>ClinicalTrials.gov: <a href="http://www.clinicaltrials.gov/ct2/show/NCT01224379">NCT01224379</a></p

Reliability of MRI findings in candidates for lumbar disc prosthesis

Introduction: Limited reliability data exist for localised magnetic resonance imaging (MRI) findings relevant to planning of treatment with lumbar disc prosthesis and later outcomes. We assessed the reliability of such findings in chronic low back pain patients who were accepted candidates for disc prosthesis. Methods: On pretreatment MRI of 170 patients (mean age 41 years; 88 women), three experienced radiologists independently rated Modic changes, disc findings and facet arthropathy at L3/L4, L4/L5 and L5/S1. Two radiologists rerated 126 examinations. For each MRI finding at each disc level, agreement was analysed using the kappa statistic and differences in prevalence across observers using a fixed effects model. Results: All findings at L3/L4 and facet arthropathy at L5/S1 had a mean prevalence <10% across observers and were not further analysed, ensuring interpretable kappa values. Overall interobserver agreement was generally moderate or good (kappa 0.40–0.77) at L4–S1 for Modic changes, nucleus pulposus signal, disc height (subjective and measured), posterior high-intensity zone (HIZ) and disc contour, and fair (kappa 0.24) at L4/L5 for facet arthropathy. Posterior HIZ at L5/S1 and severely reduced subjective disc height at L4/L5 differed up to threefold in prevalence between observers (p< 0.0001). Intraobserver agreement was mostly good or very good (kappa 0.60–1.00). Conclusion: In candidates for disc prosthesis, mostly moderate interobserver agreement is expected for localised MRI findings

Routine versus needs-based MRI in patients with prolonged low back pain: a comparison of duration of treatment, number of clinical contacts and referrals to surgery

<p>Abstract</p> <p>Background</p> <p>The routine use of radiology is normally discouraged in patients with low back pain (LBP). Magnetic Resonance Imaging (MRI) provides clinicians and patients with detailed knowledge of spinal structures and has no known physical side effects. It is possible that insight into the pathological changes in LBP patients could affect patient management. However, to our knowledge, this has never been tested. Until June 2006, all patients at our specialised out-patient public clinic were referred for MRI on the basis of clinical indications, economic constraints, and availability of MRI (the "needs-based MRI" group). As a new approach, we now refer all patients who meet certain criteria for routine up-front MRI before the clinical examination (the "routine MRI" group).</p> <p>Objectives</p> <p>The aims of this study were to investigate if these two MRI approaches resulted in differences in: (1) duration of treatment, (2) number of contacts with clinicians, and (3) referral for surgery.</p> <p>Design</p> <p>Comparison of two retrospective clinical cohorts.</p> <p>Method</p> <p>Files were retrieved from consecutive patients in both groups. Criteria for referral were: (1) LBP or leg pain of at least 3 on an 11-point Numeric Rating Scale, (2) duration of present symptoms from 2 to12 months and (3) age above 18 years. A comparison was made between the "needs-based MRI" and "routine MRI" groups on the outcomes of duration of treatment and use of resources.</p> <p>Results</p> <p>In all, 169 "needs-based MRI" and 208 "routine MRI" patient files were identified. The two groups were similar in age, sex, and severity of LBP. However, the median duration of treatment for the "needs-based MRI" group was 160 versus 115 days in the "routine MRI" group (p = 0.0001). The median number of contacts with clinicians for the "needs-based MRI" group was 4 versus 3 for the "routine MRI" group (p = 0.003). There was no difference between the two approaches in frequency of referral for back surgery (p = 0.81). When the direct clinical costs were compared, the "routine MRI" group was less costly but only by €11.</p> <p>Conclusion</p> <p>In our clinic, the management strategy of routinely performing an up-front MRI at the start of treatment did reduce the duration of treatment and number of contacts with clinicians, and did not increase the rate of referral for back surgery. Also, the direct costs were not increased.</p

The evolution of degenerative marrow (Modic) changes in the cervical spine in neck pain patients

PURPOSE: To evaluate the natural course of end plate marrow (Modic) changes (MC) in the cervical spine on MRI scans of patients with neck pain. A few longitudinal studies have assessed the development of MC over time in the lumbar spine but only two recent studies evaluated MC in the cervical spine in asymptomatic volunteers and those with whiplash. Thus, this study now reports on the natural course of MC in the cervical spine in symptomatic patients. METHODS: From the cervical MRI scans of 426 neck pain patients (mean age 61.2 years), 64 patients had follow-up MRI studies. The prevalence and types of MC were retrospectively assessed on the follow-up scans and compared to the original MRI findings. RESULTS: With an average of 2.5 years between the two MRI scans, the prevalence of MC type 1 (MC1) noted at baseline (7.4 % or 19 motion segments) slightly increased (8.2 % or 21 segments) but the prevalence of MC2 (14.5 % or 37 segments) increased considerably (22.3 % or 57 segments). In addition, 14 new MC1 segments and 8 new MC2 segments were noted. Twelve segments with MC1 at baseline converted to MC2 at follow-up. No conversion from MC2 to MC1 or reverting to a normal image was observed. CONCLUSIONS: MC in the cervical spine are a dynamic phenomenon similar to the lumbar spine

Do MRI findings identify patients with chronic low back pain and Modic changes who respond best to rest or exercise: A subgroup analysis of a randomised controlled trial

Background: No previous clinical trials have investigated MRI findings as effect modifiers for conservative treatment of low back pain. This hypothesis-setting study investigated if MRI findings modified response to rest compared with exercise in patients with chronic low back pain and Modic changes. Methods: This study is a secondary analysis of a randomised controlled trial comparing rest with exercise. Patients were recruited from a specialised outpatient spine clinic and included in a clinical trial if they had chronic low back pain and an MRI showing Modic changes. All patients received conservative treatment while participating in the trial. Five baseline MRI findings were investigated as effect modifiers: Modic changes Type 1 (any size), large Modic changes (any type), large Modic changes Type 1, severe disc degeneration and large disc herniation. The outcome measure was change in low back pain intensity measured on a 0-10 point numerical rating scale at 14-month follow-up (n = 96). An interaction = 1.0 point (0-10 scale) between treatment group and MRI findings in linear regression was considered clinically important. Results: The interactions for Modic Type 1, with large Modic changes or with large Modic changes Type 1 were all potentially important in size (-0.99 (95% CI -3.28 to 1.29), -1.49 (-3.73 to 0.75), -1.49 (-3.57 to 0.58), respectively) but the direction of the effect was the opposite to what we had hypothesized-that people with these findings would benefit more from rest than from exercise. The interactions for severe disc degeneration (0.74 (-1.40 to 2.88)) and large disc herniation (-0.92 (3.15 to 1.31)) were less than the 1.0-point threshold for clinical importance. As expected, because of the lack of statistical power, no interaction term for any of the MRI findings was statistically significant. Conclusions: Three of the five MRI predictors showed potentially important effect modification, although the direction of the effect was surprising and confidence intervals were wide so very cautious interpretation is required. Further studies with adequate power are warranted to study these and additional MRI findings as potential effect modifiers for common interventions

The role of intradiscal steroids in the treatment of discogenic low back pain

LBP is one of the most common reasons for visiting a doctor and is the most common cause of disability under age 45.Amongst a variety of etiologies, internal disc disruption (IDD) has been postulated as an important cause of low back pain. Treating discogenic low back pain continues to be a challenge to physicians. Inflammation, either from direct chemical irritation or secondary to an autoimmune response to the nucleus pulposus has been implicated as the primary pain source. Both steroids and non-steroidal anti-inflammatory drugs have partial effectiveness in treating pain associated with inflammation. Therefore, the rationale for using intradiscal steroids is to suppress the inflammation within the disc, thereby alleviating the patient’s symptoms. The goal of this article is to review the literature regarding the efficacy of intradiscal steroids to treat low back pain of discogenic origin