1. Lumbosacral radicular pain

Introduction: Patients suffering lumbosacral radicular pain report radiating pain in one or more lumbar or sacral dermatomes. In the general population, low back pain with leg pain extending below the knee has an annual prevalence that varies from 9.9% to 25%. Methods: The literature on the diagnosis and treatment of lumbosacral radicular pain was reviewed and summarized. Results: Although a patient's history, the pain distribution pattern, and clinical examination may yield a presumptive diagnosis of lumbosacral radicular pain, additional clinical tests may be required. Medical imaging studies can demonstrate or exclude specific underlying pathologies and identify nerve root irritation, while selective diagnostic nerve root blocks can be used to confirm the affected level(s). In subacute lumbosacral radicular pain, transforaminal corticosteroid administration provides short-term pain relief and improves mobility. In chronic lumbosacral radicular pain, pulsed radiofrequency (PRF) treatment adjacent to the spinal ganglion (DRG) can provide pain relief for a longer period in well-selected patients. In cases of refractory pain, epidural adhesiolysis and spinal cord stimulation can be considered in experienced centers. Conclusions: The diagnosis of lumbosacral radicular pain is based on a combination of history, clinical examination, and additional investigations. Epidural steroids can be considered for subacute lumbosacral radicular pain. In chronic lumbosacral radicular pain, PRF adjacent to the DRG is recommended. SCS and epidural adhesiolysis can be considered for cases of refractory pain in specialized centers.</p

The appropriate management of persisting pain after spine surgery: a European panel study with recommendations based on the RAND/UCLA method

Purpose: Management of patients with persisting pain after spine surgery (PPSS) shows significant variability, and there is limited evidence from clinical studies to support treatment choice in daily practice. This study aimed to develop patient-specific recommendations on the management of PPSS. Methods: Using the RAND/UCLA appropriateness method (RUAM), an international panel of 6 neurosurgeons, 6 pain specialists, and 6 orthopaedic surgeons assessed the appropriateness of 4 treatment options (conservative, minimally invasive, neurostimulation, and re-operation) for 210 clinical scenarios. These scenarios were unique combinations of patient characteristics considered relevant to treatment choice. Appropriateness had to be expressed on a 9-point scale (1 = extremely inappropriate, 9 = extremely appropriate). A treatment was considered appropriate if the median score was ≥ 7 in the absence of disagreement (≥ 1/3 of ratings in each of the opposite sections 1–3 and 7–9). Results: Appropriateness outcomes showed clear and specific patterns. In 48% of the scenarios, exclusively one of the 4 treatments was appropriate. Conservative treatment was usually considered appropriate for patients without clear anatomic abnormalities and for those with new pain differing from the original symptoms. Neurostimulation was considered appropriate in the case of (predominant) neuropathic leg pain in the absence of conditions that may require surgical intervention. Re-operation could be considered for patients with recurrent disc, spinal/foraminal stenosis, or spinal instability. Conclusions: Using the RUAM, an international multidisciplinary panel established criteria for appropriate treatment choice in patients with PPSS. These may be helpful to educate physicians and to improve consistency and quality of care. Graphical abstract: These slides can be retrieved under Electronic Supplementary Material. [Figure not available: see fulltext.

Radiofrequency Treatment Adjacent to the Cervical Dorsal Root Ganglion

Cervical radicular pain is pain perceived in the arm, shooting or electric in quality, caused by irritation or injury of a cervical spinal nerve root. It affects approximately 1 in 1000 adults annually. When cervical radicular pain does not resolve spontaneously within 3 months, serious underlying pathologies, such as infection and cancer, should be excluded before offering further symptomatic treatment. The neurological examination includes sensory, motor, and reflex evaluation. The clinical tests: neck compression test or Spurling test, shoulder abduction test, Valsalva maneuver, axial traction test, and Elvey’s upper limb tension test have a high specificity but a low sensitivity. The determination of the symptomatic level is done with diagnostic selective nerve root blocks. The prognostic block is performed by injecting a radio-opaque mixture of iohexol and lidocaine around the nerve. The block is considered positive when it results in minimum 50% pain reduction, measured on the visual analogue scale within 30 min. Radiofrequency treatment applies high frequency current adjacent to the dorsal root ganglion. The aim is to increase the electrode tip temperature to 67°C. This temperature is maintained during 60s. The pulsed radiofrequency current is applied in small bursts at 45 V and the temperature is kept below 42°C. There is evidence from two randomized controlled trials that radiofrequency treatment could be used for the treatment of cervical radicular pain. The outcome of pulsed radiofrequency treatment adjacent to the cervical dorsal root ganglion is supported by observational studies and a randomized controlled trial. There a few side effects with radiofrequency treatment and when they occur, they are usually minor and transient. Deafferentation pain is rarely occurring with conventional radiofrequency. No side effects and complications of pulsed radiofrequency treatment adjacent to the cervical dorsal root ganglion have been reported