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1.  Herniated lumbar disc 
Clinical Evidence  2011;2011:1118.
Introduction
Herniated lumbar disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space. The highest prevalence is among people aged 30 to 50 years, with a male to female ratio of 2:1. There is little evidence to suggest that drug treatments are effective in treating herniated disc.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of drug treatments, non-drug treatments, and surgery for herniated lumbar disc? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 37 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: acupuncture, advice to stay active, analgesics, antidepressants, bed rest, corticosteroids (epidural injections), cytokine inhibitors (infliximab), discectomy (automated percutaneous, laser, microdiscectomy, standard), exercise therapy, heat, ice, massage, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), percutaneous disc decompression, spinal manipulation, and traction.
Key Points
Herniated lumbar disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space. The highest prevalence is among people aged 30 to 50 years, with a male to female ratio of 2:1.
There is little high-quality evidence to suggest that drug treatments are effective in treating herniated disc. NSAIDs and cytokine inhibitors do not seem to improve symptoms of sciatica caused by disc herniation.We found no RCT evidence examining the effects of analgesics, antidepressants, or muscle relaxants in people with herniated disc. We found several RCTs that assessed a range of different measures of symptom improvement and found inconsistent results, so we are unable to draw conclusions on effects of epidural injections of corticosteroids.
With regard to non-drug treatments, spinal manipulation seems more effective at relieving local or radiating pain in people with acute back pain and sciatica with disc protrusion compared with sham manipulation, although concerns exist regarding possible further herniation from spinal manipulation in people who are surgical candidates. Neither bed rest nor traction seem effective in treating people with sciatica caused by disc herniation.We found insufficient RCT evidence about advice to stay active, acupuncture, massage, exercise, heat, or ice to judge their efficacy in treating people with herniated disc.
About 10% of people have sufficient pain after 6 weeks for surgery to become a consideration. Standard discectomy and microdiscectomy seem to increase self-reported improvement to a similar extent.We found insufficient evidence judging the effects of automated percutaneous discectomy, laser discectomy, or percutaneous disc decompression.
PMCID: PMC3275148  PMID: 21711958
2.  Herniated lumbar disc 
Clinical Evidence  2009;2009:1118.
Introduction
Herniated lumbar disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space. The highest prevalence is among people aged 30-50 years, with a male to female ratio of 2:1. There is little evidence to suggest that drug treatments are effective in treating herniated disc.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of drug treatments, non-drug treatments, and surgery for herniated lumbar disc? We searched: Medline, Embase, The Cochrane Library, and other important databases up to July 2008 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 49 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: acupuncture, advice to stay active, analgesics, antidepressants, bed rest, corticosteroids (epidural injections), cytokine inhibitors (infliximab), discectomy (automated percutaneous, laser, microdisectomy, standard), exercise therapy, heat, ice, massage, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), percutaneous disc decompression, spinal manipulation, and traction.
Key Points
Herniated lumbar disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space. The highest prevalence is among people aged 30-50 years, with a male to female ratio of 2:1.
There is little evidence to suggest that drug treatments are effective in treating herniated disc. NSAIDs and cytokine inhibitors don’t seem to improve symptoms of sciatica caused by disc herniation.We found no evidence examining the effectiveness of analgesics, antidepressants, or muscle relaxants in people with herniated disc.We found no evidence of sufficient quality to judge the effectiveness of epidural injections of corticosteroids.
With regard to non-drug treatments, spinal manipulation seems to be more effective at relieving local or radiating pain in people with acute back pain and sciatica with disc protrusion compared with sham manipulation, although concerns exist regarding possible further herniation from spinal manipulation in people who are surgical candidates. Neither bed rest nor traction seem effective in treating people with sciatica caused by disc herniation.We found insufficient evidence about advice to stay active, acupuncture, massage, exercise, heat, or ice to judge their efficacy in treating people with herniated disc.
About 10% of people have sufficient pain after 6 weeks for surgery to become a consideration. Both standard discectomy and microdiscectomy seem to increase self-reported improvement to a similar extent.We found insufficient evidence judging the effectiveness of automated percutaneous discectomy, laser discectomy, or percutaneous disc decompression.
PMCID: PMC2907819  PMID: 19445754
3.  Children’s sedentary behaviour: descriptive epidemiology and associations with objectively-measured sedentary time 
BMC Public Health  2013;13:1092.
Background
Little is known regarding the patterning and socio-demographic distribution of multiple sedentary behaviours in children. The aims of this study were to: 1) describe the leisure-time sedentary behaviour of 9–10 year old British children, and 2) establish associations with objectively-measured sedentary time.
Methods
Cross-sectional analysis in the SPEEDY study (Sport, Physical activity and Eating behaviour: Environmental Determinants in Young people) (N=1513, 44.3% boys). Twelve leisure-time sedentary behaviours were assessed by questionnaire. Objectively-measured leisure-time sedentary time (Actigraph GT1M, <100 counts/minute) was assessed over 7 days. Differences by sex and socioeconomic status (SES) in self-reported sedentary behaviours were tested using Kruskal-Wallis tests. The association between objectively-measured sedentary time and the separate sedentary behaviours (continuous (minutes) and categorised into 'none’ 'low’ or 'high’ participation) was assessed using multi-level linear regression.
Results
Sex differences were observed for time spent in most sedentary behaviours (all p ≤ 0.02), except computer use. Girls spent more time in combined non-screen sedentary behaviour (median, interquartile range: girls: 770.0 minutes, 390.0-1230.0; boys: 725.0, 365.0 - 1182.5; p = 0.003), whereas boys spent more time in screen-based behaviours (girls: 540.0, 273.0 - 1050.0; boys: 885.0, 502.5 - 1665.0; p < 0.001). Time spent in five non-screen behaviours differed by SES, with higher values in those of higher SES (all p ≤ 0.001). Regression analyses with continuous exposures indicated that reading (β = 0.1, p < 0.001) and watching television (β = 0.04, p < 0.01) were positively associated with objectively-measured sedentary time, whilst playing board games (β = -0.12, p < 0.05) was negatively associated. Analysed in categorical form, sitting and talking (vs. none: 'low’ β = 26.1,ns; 'high’ 30.9, p < 0.05), playing video games (vs. none: 'low’ β = 49.1, p < 0.01; 'high’ 60.2, p < 0.01) and watching television (vs. lowest tertile: middle β = 22.2,ns; highest β = 31.9, p < 0.05) were positively associated with objectively-measured sedentary time whereas talking on the phone (vs. none: 'low’ β = -38.5, p < 0.01; 'high’ -60.2, p < 0.01) and using a computer/internet (vs. none: 'low’ β = -30.7, p < 0.05; 'high’ -4.2,ns) were negatively associated.
Conclusions
Boys and girls and children of different socioeconomic backgrounds engage in different leisure-time sedentary behaviours. Whilst a number of behaviours may be predictive of total sedentary time, collectively they explain little overall variance. Future studies should consider a wide range of sedentary behaviours and incorporate objective measures to quantify sedentary time where possible.
doi:10.1186/1471-2458-13-1092
PMCID: PMC4222753  PMID: 24274070
Children; Sedentary behaviour; TV viewing; Accelerometer; Socioeconomic status
4.  Correlation between Epidurographic Contrast Flow Patterns and Clinical Effectiveness in Chronic Lumbar Discogenic Radicular Pain Treated with Epidural Steroid Injections Via Different Approaches 
The Korean Journal of Pain  2014;27(4):353-359.
Background
Epidural steroid injections are an accepted procedure for the conservative management of chronic backache caused by lumbar disc pathology. The purpose of this study was to evaluate the epidurographic findings for the midline, transforaminal and parasagittal approaches in lumbar epidural steroid injections, and correlating them with the clinical improvement.
Methods
Sixty chronic lower back pain patients with unilateral radiculitis from a herniated/degenerated disc were enrolled. After screening the patients according to the exclusion criteria and randomly allocating them to 3 groups of 20 patients, fluoroscopic contrast enhanced epidural steroids were injected via midline (group 1), transforaminal (group 2) and parasagittal interlaminar (group 3) approaches at the level of the pathology. The fluoroscopic patterns of the three groups were studied and correlated with the clinical improvement measured by the VAS over the next 3 months; any incidences of complications were recorded.
Results
The transforaminal group presented better results in terms of VAS reduction than the midline and parasagittal approach groups (P < 0.05). The epidurography showed a better ventral spread for both the transforaminal (P < 0.001) and the paramedian approaches (P < 0.05), as compared to the midline approach. The nerve root filling was greater in the transforaminal group (P < 0.001) than in the other two groups. The ventral spread of the contrast agent was associated with improvement in the VAS score and this difference was statistically significant in group 1 (P < 0.05), and highly significant in groups 2 and 3 (P < 0.001). In all the groups, any complications observed were transient and minor.
Conclusions
The midline and paramedian approaches are technically easier and statistically comparable, but clinically less efficacious than the transforaminal approach. The incidence of ventral spread and nerve root delineation show a definite correlation with clinical improvement. However, an longer follow-up period is advisable for a better evaluation of the actual outcom.
doi:10.3344/kjp.2014.27.4.353
PMCID: PMC4196501  PMID: 25317285
epidural steroid injection; fluoroscopy; midline interlaminar; parasagittal interlaminar; transforaminal
5.  Analysis of Efficacy Differences between Caudal and Lumbar Interlaminar Epidural Injections in Chronic Lumbar Axial Discogenic Pain: Local Anesthetic Alone vs. Local Combined with Steroids 
Study Design: Comparative assessment of randomized controlled trials of caudal and lumbar interlaminar epidural injections in chronic lumbar discogenic pain.
Objective: To assess the comparative efficacy of caudal and lumbar interlaminar approaches of epidural injections in managing axial or discogenic low back pain.
Summary of Background Data: Epidural injections are commonly performed utilizing either a caudal or lumbar interlaminar approach to treat chronic lumbar axial or discogenic pain, which is pain exclusive of that associated with a herniated intervertebral disc, or that is due to degeneration of the zygapophyseal joints, or due to dysfunction of the sacroiliac joints, respectively. The literature on the efficacy of epidural injections in managing chronic axial lumbar pain of presumed discogenic origin is limited.
Methods: The present analysis is based on 2 randomized controlled trials of chronic axial low back pain not caused by disc herniation, radiculitis, or facet joint pain, utilizing either a caudal or lumbar interlaminar approach, with a total of 240 patients studied, and a 24-month follow-up. Patients were assigned to receive either local anesthetic only or local anesthetic with a steroid in each 60 patient group.
Results: The primary outcome measure was significant improvement, defined as pain relief and functional status improvement of at least 50% from baseline, which was reported at 24-month follow-ups in 72% who received local anesthetic only with a lumbar interlaminar approach and 54% who received local anesthetic only with a caudal approach. In patients receiving local anesthetic with a steroid, the response rate was 67% for those who had a lumbar interlaminar approach and 68% for those who had a caudal approach at 12 months. The response was significantly better in the lumbar interlaminar group who received local anesthetic only, 77% versus 56% at 12 months and 72% versus 54% at 24 months.
Conclusion: This assessment shows that in patients with axial or discogenic pain in the lumbar spine after excluding facet joint and SI Joint pain, epidural injections of local anesthetic by the caudal or lumbar interlaminar approach may be effective in managing chronic low back pain with a potential superiority for a lumbar interlaminar approach over a caudal approach.
doi:10.7150/ijms.10870
PMCID: PMC4323359
Chronic low back pain; axial low back pain; lumbar discogenic pain; caudal epidural injections; lumbar interlaminar epidural injections.
6.  Temporal trends in non-occupational sedentary behaviours from Australian Time Use Surveys 1992, 1997 and 2006 
Background
Current epidemiological data highlight the potential detrimental associations between sedentary behaviours and health outcomes, yet little is known about temporal trends in adult sedentary time. This study used time use data to examine population trends in sedentary behaviours in non-occupational domains and more specifically during leisure time.
Methods
We conducted secondary analysis of population representative data from the Australian Time Use Surveys 1992, 1997 and 2006 involving respondents aged 20 years and over with completed time use diaries for two days. Weighted samples for each survey year were: n = 5851 (1992), n = 6419 (1997) and n = 5505 (2006). We recoded all primary activities by domain (sleep, occupational, transport, leisure, household, education) and intensity (sedentary, light, moderate). Adjusted multiple linear regressions tested for differences in time spent in non-occupational sedentary behaviours in 1992 and 1997 with 2006 as the reference year.
Results
Total non-occupational sedentary time was slightly lower in 1997 than in 2006 (mean = 894 min/2d and 906 min/2d, respectively; B = −11.2; 95%CI: -21.5, -0.9). Compared with 2006, less time was spent in 1997 in sedentary transport (B-6.7; 95%CI: -10.4, -3.0) and sedentary education (B = −6.3; 95%CI: -10.5, -2.2) while household and leisure sedentary time remained stable. Time engaged in different types of leisure-time sedentary activities changed between 1997 and 2006: leisure-time computer use increased (B = −26.7; 95%CI: -29.5, -23.8), while other leisure-time sedentary behaviours (e.g., reading, listening to music, hobbies and crafts) showed small concurrent reductions. In 1992, leisure screen time was lower than in 2006: TV-viewing (B = −24.2; 95%CI: -31.2, -17.2), computer use (B = −35.3; 95%CI: -37.7, -32.8). In 2006, 90 % of leisure time was spent sedentary, of which 53 % was screen time.
Conclusions
Non-occupational sedentary time has increased slightly from 1997 to 2006 in the Australian adult population. This seems to be the result of small increases in sedentary transport and education time while sedentary household and leisure time were stable over this time period. However, almost all leisure time is spent sedentary and the composition of sedentary leisure time changed between 1992 and 2006 towards a larger proportion being screen-based activities. This could be an important observation for public health, as most of the evidence on the detrimental effects of sedentary behaviour is around watching television and health.
doi:10.1186/1479-5868-9-76
PMCID: PMC3419123  PMID: 22713740
7.  The contribution of office work to sedentary behaviour associated risk 
BMC Public Health  2013;13:296.
Background
Sedentary time has been found to be independently associated with poor health and mortality. Further, a greater proportion of the workforce is now employed in low activity occupations such as office work. To date, there is no research that specifically examines the contribution of sedentary work to overall sedentary exposure and thus risk. The purpose of the study was to determine the total exposure and exposure pattern for sedentary time, light activity and moderate/vigorous physical activity (MVPA) of office workers during work and non-work time.
Methods
50 office workers from Perth, Australia wore an Actical (Phillips, Respironics) accelerometer during waking hours for 7 days (in 2008–2009). Participants recorded wear time, waking hours, work hours and daily activities in an activity diary. Time in activity levels (as percentage of wear time) during work and non-work time were analysed using paired t-tests and Pearson’s correlations.
Results
Sedentary time accounted for 81.8% of work hours (light activity 15.3% and MVPA 2.9%), which was significantly greater than sedentary time during non-work time (68.9% p < 0.001). Office workers experienced significantly more sustained sedentary time (bouts >30 minutes) and significantly less brief duration (0–10 minutes) light intensity activity during work hours compared to non-work time (p < 0.001). Further, office workers had fewer breaks in sedentary time during work hours compared to non-work time (p < 0.001).
Conclusions
Office work is characterised by sustained sedentary time and contributes significantly to overall sedentary exposure of office workers.
doi:10.1186/1471-2458-13-296
PMCID: PMC3651291  PMID: 23557495
8.  Physical activity, sedentary behavior and total wellness changes among sedentary adults: a 4-week randomized controlled trial 
Background
The construct of total wellness includes a holistic approach to the body, mind and spirit components of life. While the health benefits of reducing sedentary behavior and increasing physical activity are well documented, little is known about the influence on total wellness of an internet-based physical activity monitor designed to help people to achieve higher physical activity levels.
Purpose
The purpose of this four-week, personal activity monitor-based intervention program was to reduce sedentary behavior and increase physical activity levels in daily living for sedentary adults and to determine if these changes would also be associated with improvement in total wellness.
Methods
Twenty-two men and 11 women (27 years ± 4.0) were randomly assigned to either an intervention (n = 18) or control group (n = 15). The intervention group interacted with an online personal activity monitor (Gruve Solution™) designed to reduce sedentary time and increase physical activity during activities of daily living. The control group did not interact with the monitor, as they were asked to follow their normal daily physical activities and sedentary behavior routines. The Wellness Evaluation of Lifestyle (WEL) inventory was used to assess total wellness. Sedentary time, light, walking, moderate and vigorous intensity physical activities were assessed for both intervention and control groups at baseline and at week-4 by the 7-day Sedentary and Light Intensity Physical Activity Log (7-day SLIPA Log) and the International Physical Activity Questionnaire (IPAQ).
Results
Significant increases in pre-post total wellness scores (from 64% ± 5.7 to 75% ± 8.5) (t (17) = -6.5, p < 0.001) were observed in the intervention group by the end of week four. Intervention participants decreased their sedentary time (21%, 2.3 hours/day) and increased their light (36.7%, 2.5 hours/day), walking (65%, 1057 MET-min/week), moderate (67%, 455 MET-min/week) and vigorous intensity (60%, 442 MET-min/week) physical activity (all p < 0.001). No significant differences for total wellness were observed between the groups at baseline and no pre-post significant differences were observed for any outcome variable in the control group.
Conclusion
Total wellness is improved when sedentary, but sufficiently physically active adults, reduce sedentary time and increase physical activity levels (i.e. light, waking, moderate and vigorous).
doi:10.1186/1477-7525-11-183
PMCID: PMC4228472  PMID: 24168638
Sedentary behavior; Wellness evaluation of lifestyle (WEL); IPAQ; 7-day SLIPA Log
9.  Efficacy of Epidural Neuroplasty Versus Transforaminal Epidural Steroid Injection for the Radiating Pain Caused by a Herniated Lumbar Disc 
Annals of Rehabilitation Medicine  2013;37(6):824-831.
Objective
To compare the treatment effects of epidural neuroplasty (NP) and transforaminal epidural steroid injection (TFESI) for the radiating pain caused by herniated lumbar disc.
Methods
Thirty-two patients diagnosed with herniated lumbar disc through magnetic resonance imaging or computed tomography were included in this study. Fourteen patients received an epidural NP and eighteen patients had a TFESI. The visual analogue scale (VAS) and functional rating index (FRI) were measured before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment.
Results
In the epidural NP group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.00±1.52, 4.29±1.20, 2.64±0.93, 1.43±0.51 and those of FRI were 23.57±3.84, 16.50±3.48, 11.43±2.44, 7.00±2.15. In the TFESI group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.22±2.05, 4.28±1.67, 2.56±1.04, 1.33±0.49 and those of FRI were 22.00±6.64, 16.22±5.07, 11.56±4.18, 8.06±1.89. During the follow-up period, the values of VAS and FRI within each group were significantly reduced (p<0.05) after the treatment. But there were no significant differences between the two groups statistically.
Conclusion
Epidural NP and TFESI are equally effective treatments for the reduction of radiating pain and for improvement of function in patients with a herniated lumbar disc. We recommend that TFESI should be primarily applied to patients who need interventional spine treatment, because it is easier and more cost-effective than epidural NP.
doi:10.5535/arm.2013.37.6.824
PMCID: PMC3895522  PMID: 24466517
Epidural neuroplasty; Transforaminal epidural steroid injection; Radiating pain; Herniated lumbar disc
10.  Development of a questionnaire to assess sedentary time in older persons – a comparative study using accelerometry 
BMC Geriatrics  2013;13:80.
Background
There is currently no validated questionnaire available to assess total sedentary time in older adults. Most studies only used TV viewing time as an indicator of sedentary time. The first aim of our study was to investigate the self-reported time spent by older persons on a set of sedentary activities, and to compare this with objective sedentary time measured by accelerometry. The second aim was to determine what set of self-reported sedentary activities should be used to validly rank people’s total sedentary time. Finally we tested the reliability of our newly developed questionnaire using the best performing set of sedentary activities.
Methods
The study sample included 83 men and women aged 65–92 y, a random sample of Longitudinal Aging Study Amsterdam participants, who completed a questionnaire including ten sedentary activities and wore an Actigraph GT3X accelerometer for 8 days. Spearman correlation coefficients were calculated to examine the association between self-reported time and objective sedentary time. The test-retest reliability was calculated using the intraclass correlation coefficient (ICC).
Results
Mean total self-reported sedentary time was 10.4 (SD 3.5) h/d and was not significantly different from mean total objective sedentary time (10.2 (1.2) h/d, p = 0.63). Total self-reported sedentary time on an average day (sum of ten activities) correlated moderately (Spearman’s r = 0.35, p < 0.01) with total objective sedentary time. The correlation improved when using the sum of six activities (r = 0.46, p < 0.01), and was much higher than when using TV watching only (r = 0.22, p = 0.05). The test-retest reliability of the sum of six sedentary activities was 0.71 (95% CI 0.57-0.81).
Conclusions
A questionnaire including six sedentary activities was moderately associated with accelerometry-derived sedentary time and can be used to reliably rank sedentary time in older persons.
doi:10.1186/1471-2318-13-80
PMCID: PMC3733654  PMID: 23899190
Sedentary behavior; Accelerometry; Physical activity; Aging
11.  Epidural steroid injection in patients with lumbosacral radiculopathy in Abuja, Nigeria 
Objective:
This prospective-controlled observational study looked at well-matched patients with spinal pain and radicular symptoms, caused by lumbar intervertebral disc herniation to compare the short-term clinical outcome of transforaminal and interlaminar epidural steroid injection (ESI) in a resource challenged tertiary institution in Nigeria.
Materials and Methods:
49 patients with radicular symptoms who were matched for age, symptom duration, magnetic resonance imaging findings, and pre-injection revised Oswentry Disability Index (ODI) score and Visual Analogue Scale (VAS) were assigned into ESI technique. The ODI and VAS score were analyzed immediately after an injection and upon follow-up (average 178.5 days), also with the need for repeated injections and surgical interventions over a 1-year follow-up interval.
Result:
In the transforaminal group (25 patients), there was a statistically significant improvement in the ODI scores from before the injection (ODI mean 62.4) to immediately after the injection (ODI mean 24.4, P < 0.01), and upon follow-up (ODI mean 20.8, P < 0.01). 9 patients (18.4%) required 1 or 2 repeated injections, 3 (6.1%) patients underwent surgery and 2 (4%) patients lost to follow-up. In the interlaminar group (24 patients), there was a statistically significant improvement in the ODI scores from before the injection (ODI mean 60.7) to immediately after the injection (ODI mean 30.1, P < 0.01), but not upon follow-up (ODI mean 43.2, P = 0.09). 11 (22.4%) patients required 1 or 2 repeated injection, 4 (8%) patients underwent surgery and 3 (6.1%) patients were lost to follow-up. There is an average of 2 fold improvement of transforaminal ESI over interlaminar ESI in a 40 point scale of ODI score on follow-up, which was statistically significant (P < 0.01). The VAS showed similar pattern with the ODI scores in the study.
Conclusion:
Transforaminal ESI to treat symptomatic lumbar disc herniation resulted in better short-term pain improvement and fewer long-term surgical interventions compared to interlaminar ESI.
doi:10.4103/0976-3147.98206
PMCID: PMC3409978  PMID: 22865959
Epidural injections; oswentry disability index; spinal pain
12.  Endoscopic Foraminal Decompression for Failed Back Surgery Syndrome under local Anesthesia 
Background
The most common causes of failed back surgery are residual or recurrent herniation, foraminal fibrosis and foraminal stenosis that is ignored, untreated, or undertreated. Residual back ache may also be from facetal causes or denervation and scarring of the paraspinal muscles.1–6 The original surgeon may advise his patient that nothing more can be done on the basis of his opinion that the nerve was visually decompressed by the original surgery, supported by improved post-op imaging and follow-up studies such as EMG and conduction velocity studies. Post-op imaging or electrophysiological assessment may be inadequate to explain all the reasons for residual or recurrent symptoms. Treatment of Failed back surgery by repeat traditional open revision surgery usually incorporates more extensive decompression causing increased instability and back pain, therefore necessitating fusion. The authors, having limited their practice to endoscopic MIS surgery over the last 15-20 years, report on their experience gained during that period to relieve pain by endoscopically visualizing and treating unrecognized causative patho-anatomy in FBSS.7
Methods
Thirty consecutive patients with FBSS presenting with back and leg pain that had supporting imaging diagnosis of lateral stenosis and /or residual / recurrent disc herniation, or whose pain complaint was supported by relief from diagnostic and therapeutic injections (Figure 1), were offered percutaneous transforaminal endoscopic discectomy and foraminoplasty over a repeat open procedure. Each patient sought consultation following a transient successful, partially successful or unsuccessful open translaminar surgical treatment for disc herniation or spinal stenosis. Endoscopic foraminoplasty was also performed to either decompress the bony foramen for foraminal stenosis, or foraminoplasty to allow for endoscopic visual examination of the affected traversing and exiting nerve roots in the axilla, also known as the “hidden zone” of Macnab (Figure 2).8, 9 The average follow up time was, average 40 months, minimum 12 months. Outcome data at each visit included Macnab, VAS and ODI.
A diagnostic and therapeutic epidural gram may help identify unrecognized lateral recess stenosis underestimated by MRI. An excellent result from a therapeutic block lends excellent prognosis for a more lasting and “permanent” result from transforaminal endoscopic lateral recess decompression.
Kambin's Triangle provides access to the “hidden zone” of Macnab by foraminoplasty. The foramen and lateral recess is decompressed by removing the ventral aspect and tip of the superior articular process to gain access to the axilla between the traversing and exiting nerve. FBSS contains patho-anatomy in the axilla between the traversing and exiting nerve that hides the pain generators of FBSS.
Results
The average pre-operative VAS improved from 7.2 to 4.0, and ODI 48% to 31%. While temporary dysesthesia occurred in 4 patients in the early post-operative period, all were happy, as all received additional relief of their pre-op symptoms. They were also relieved to be able to avoid “open” decompression or fusion surgery.
Conclusions / Level of Evidence 3
The transforaminal endoscopic approach is effective for FBSS due to residual/recurrent HNP and lateral stenosis. Failed initial index surgery may involve failure to recognize patho-anatomy in the axilla of the foramen housing the traversing and the exiting nerve, including the DRG, which is located cephalad and near the tip of SAP.10 The transforaminal endoscopic approach effectively decompresses the foramen and does not further destabilize the spine needing stabilization.11 It also avoids going through the previous surgical site.
Clinical Relevance
Disc narrowing as a consequence of translaminar discectomy and progressive degenerative narrowing and spondylolisthesis (Figure 3) as a natural history of degenerative disc disease can lead to central and lateral stenosis. The MRI may underestimate the degree of stenosis from a bulging or a foraminal disc protrusion and residual lateral recess stenosis. Pain can be diagnosed and confirmed by evocative discography and by clinical response to transforaminal diagnostic and therapeutic steroid injections.12 Foraminal endoscopic decompression of the lateral recess is a MIS technique that does not “burn bridges” for a more conventional approach and it adds to the surgical armamentarium of FBSS.
Cadaver Illustration of Foraminal Stenosis (courtesy of Wolfgang Rauschning). As the disc narrows, the superior articular process impinges on the exiting nerve and DRG, creating lateral recess stenosis, lumbar spondylosis, and facet arthrosis.
doi:10.14444/1022
PMCID: PMC4325507
Failed Back Surgery Syndrome(FBSS); Hidden zone; Foraminal decompression; Recurrent herniation; Lateral stenosis; Foraminal osteophyte
13.  A Prospective, Observational Study of the Relationship Between Body Mass Index and Depth of the Epidural Space During Lumbar Transforaminal Epidural Steroid Injection 
Background and Objectives
Previous studies have concluded that transforaminal epidural steroid injections (ESIs) are more effective than interlaminar injections in the treatment of radiculopathies due to lumbar intervertebral disk herniation. There are no published studies examining the depth of epidural space using a transforaminal approach. We investigated the relationship between body mass index (BMI) and the depth of the epidural space during lumbar transforaminal ESIs.
Methods
Eighty-six consecutive patients undergoing lumbar transforaminal ESI at the L3-L4, L4-L5, and L5-S1 levels were studied. Using standard protocol, the foraminal epidural space was attained using fluoroscopic guidance. The measured distance from needle tip to skin was recorded (depth to foraminal epidural space). The differences in the needle depth and BMI were analyzed using regression analysis.
Results
Needle depth was positively associated with BMI (regression coefficient [RC], 1.13; P < 0.001). The median depths (in centimeters) to the epidural space were 6.3, 7.5, 8.4, 10.0, 10.4, and 12.2 for underweight, normal, preobese, obese I, obese II, and obese III classifications, respectively. Sex (RC, 1.3; P = 0.02) and race (RC, 0.8; P = 0.04) were also significantly associated with needle depth; however, neither factor remained significant when BMI was accounted as a covariate in the regression model. Age, intervertebral level treated, and oblique angle had no predictive value on foraminal depth (P > 0.2).
Conclusion
There is a positive association between BMI and transforaminal epidural depth, but not with age, sex, race, oblique angle, or intervertebral level.
doi:10.1097/AAP.0b013e31819a12ba
PMCID: PMC2715548  PMID: 19282707
14.  Functional results and the risk factors of reoperations after lumbar disc surgery 
European Spine Journal  2004;14(1):43-48.
Factors such as driving motor vehicles, sedentary occupations, vibration, smoking, previous full-term pregnancies, physical inactivity, increased body mass index (BMI), and a tall stature are associated with symptomatic disc herniations. Fitness and strength is postulated to protect an individual from disc rupture. The objective of our study was to determine the pain levels and differences of functional and economic situations of patients who had undergone one or more than one operation due to lumbar disc herniation and to put forward the effect of risk factors that may be potential, especially from the aspect of undergoing reoperation. Patients who had undergone one (n=46) or more than one operation (n=34) due to lumbar disc herniation were included in the study. It was a prospective study with evaluation on the day the patients were discharged and at second and sixth months after lumbar disc operation. The Oswestry Disability Index (ODI) was used in determining the functional disability associated with back pain; the Prolo Functional Economic Rating Scale (Prolo scale) was used in determining the effect of back pain on functional and economic situations. In the ODI measurements made in the postoperative second and sixth months, significant differences appeared in favor of patients who had undergone one operation (p<0.05). According to the Prolo scale, it was found that the economic situation was better in the sixth month and the functional situation was better in the second and sixth months in patients having undergone one operation (p<0.05). The logistic regression analysis demonstrated that the lack of regular physical exercise was a significant predictor for reoperation (OR, 4.595; CI, 1.38–15.28), whereas gender, age, BMI, occupation, or smoking did not indicate so much significance as regular exercise.
doi:10.1007/s00586-004-0695-3
PMCID: PMC3476671  PMID: 15490256
Lumbar disc surgery; Reoperations; Risk factors; Exercise
15.  Epidural Steroid Injections Are Associated with Less Improvement in the Treatment of Lumbar Spinal Stenosis: A subgroup analysis of the SPORT 
Spine  2013;38(4):279-291.
Summary of Background Data
Lumbar spinal stenosis is a common incidental finding among adults over the age of 60, The use of ESI in these patients is common, although there is little evidence in the literature to demonstrate the long-term benefit of ESI in the treatment of lumbar stenosis.
Objective
The hypothesis of this study was that patients who received epidural steroid injections (ESI) during initial treatment as part of the Spine Patient Outcomes Research Trial (SPORT) would have improved clinical outcomes and a lower rate of crossover to surgery compared to patients who did not receive ESI.
Methods
Patients with lumbar spinal stenosis who received epidural steroid injections within the first three months of enrollment in SPORT (ESI) were compared to patients who did not receive epidural injections during the first three months of the study (No ESI).
Results
There were 69 ESI patients and 207 No-ESI patients. There were no significant differences in demographic factors, baseline clinical outcome scores, or operative details although there was a significant increase in baseline preference for nonsurgical treatment among ESI patients (62% vs. 33%, p <0.001). There was an average 26 minute increase in operative time and an increased length of stay by 0.9 days among the ESI patients who ultimately underwent surgical treatment. Averaged over four years, there was significantly less improvement in SF36 PF among surgically treated ESI patients (ESI 14.8 vs. No-ESI 22.5, p=0.025). In addition, there was also significantly less improvement among the nonsurgically treated patients in SF36 BP (ESI 7.3 vs. No-ESI 16.7, p=0.007) and SF36 PF (ESI 5.5 vs. No-ESI 15.2, p=0.009). Of the patients assigned to surgical treatment, there was a significantly increased crossover to nonsurgical treatment among patients who received an ESI (ESI 33% vs. No ESI 11%, p=0.012). Of the patients assigned to non-operative treatment, there was a significantly increased crossover to surgical treatment in the ESI patients (ESI 58% vs. No ESI 32%, p=0.003).
Conclusion
Despite equivalent baseline status, ESI were associated with significantly less improvement at four years among all patients with spinal stenosis in SPORT. Furthermore, ESI were associated with longer duration of surgery and longer hospital stay. There was no improvement in outcome with ESI whether patients were treated surgically or nonsurgically.
doi:10.1097/BRS.0b013e31827ec51f
PMCID: PMC3622047  PMID: 23238485
Epidural Steroid Injection; lumbar stenosis; Nonsurgical Treatment; pain management
16.  Higher preoperative Oswestry Disability Index is associated with better surgical outcome in upper lumbar disc herniations 
European Spine Journal  2007;17(1):117-121.
To evaluate the surgical outcome in terms of functional and subjective recovery, patients who needed discectomies at L1–L2, L2–L3 and L3–L4 levels were compared with an age and sex-matched group of patients who required L4–L5 and L5–S1 discectomies. We prospectively enrolled 50 consecutive patients, referred to our center, who had L1–L2, L2–L3 and L3–L4 herniations and required surgical intervention. Likewise, a comparative group of 50 consecutive patients with herniations at L4–L5 and L5–S1 were selected. All 100 patients were treated and followed for a 1 year period. Physical examination findings as well as Oswestry Disability Questionnaire before surgery were recorded. After 1 year, patients were requested to fill the same questionnaire. Significant decline in the Oswestry Disability Index (ODI) scores was considered to be a measure of functional improvement and recovery. The mean age of patients with upper lumbar disc herniation (L1–L2, L2–L3, L3–L4) was 45.7 years and patients with lower lumbar disc herniation (L4–L5, L5–S1) had a mean age of 41.2 years. There was no statistically significant difference in age between the two groups. The preoperative Oswestry Disability (ODI) Index score had a statistically significant impact on ODI score improvement after surgery in both lower and upper lumbar disc groups. All 100 patients with either lower or upper lumbar disc herniation had statistically significant ODI change after surgical intervention (P < 0.0001 for both groups). However, patients with upper disc herniations and moderate preoperative disability (ODI of 21–40%) did not show significant improvement, while patients with ODI greater than 40% had significant reduction (P = 0.018). Surprisingly, as many as 25% of the former had even an increase in ODI scores after surgery. Gender was also a conspicuous factor in determining the surgical outcome of patients with upper lumbar disc herniation, and male patients had more reduction in ODI score than female patients (P = 0.007). Since the functional recovery in patients with herniated lumbar disc, especially upper lumbar herniation, is influenced by preoperative ODI scores, the use of ODI or any other standard pain assessment tool is a sensible consideration as an inherent investigative method to preclude unfavorable surgical outcome.
doi:10.1007/s00586-007-0527-3
PMCID: PMC2365528  PMID: 17972115
Upper lumbar disc; Oswestry Disability Index; Surgical outcome
17.  Reliability and Validity of a Domain-Specific Last 7-d Sedentary Time Questionnaire 
Supplemental digital content is available in the text.
ABSTRACT
Purpose
The objective of this study is to examine test–retest reliability, criterion validity, and absolute agreement of a self-report, last 7-d sedentary behavior questionnaire (SIT-Q-7d), which assesses total daily sedentary time as an aggregate of sitting/lying down in five domains (meals, transportation, occupation, nonoccupational screen time, and other sedentary time). Dutch (DQ) and English (EQ) versions of the questionnaire were examined.
Methods
Fifty-one Flemish adults (ages 39.4 ± 11.1 yr) wore a thigh accelerometer (activPAL3™) and simultaneously kept a domain log for 7 d. The DQ was subsequently completed twice (median test–retest interval: 3.3 wk). Thigh-acceleration sedentary time was log annotated to create comparable domain-specific and total sedentary time variables. Four hundred two English adults (ages 49.6 ± 7.3 yr) wore a combined accelerometer and HR monitor (Actiheart®) for 6 d to objectively measure total sedentary time. The EQ was subsequently completed twice (median test–retest interval: 3.4 wk). In both samples, the questionnaire reference frame overlapped with the criterion measure administration period. All participants had five or more valid days of criterion data, including one or more weekend day.
Results
Test–retest reliability (intraclass correlation coefficient (95% CI)) was fair to good for total sedentary time (DQ: 0.68 (0.50–0.81); EQ: 0.53 (0.44–0.62)) and poor to excellent for domain-specific sedentary time (DQ: from 0.36 (0.10–0.57) (meals) to 0.66 (0.46–0.79) (occupation); EQ: from 0.45 (0.35–0.54) (other sedentary time) to 0.76 (0.71–0.81) (meals)). For criterion validity (Spearman rho), significant correlations were found for total sedentary time (DQ: 0.52; EQ: 0.22; all P <0.001). Compared with domain-specific criterion variables (DQ), modest-to-strong correlations were found for domain-specific sedentary time (from 0.21 (meals) to 0.76 (P < 0.001) (screen time)). The questionnaire generally overestimated sedentary time compared with criterion measures.
Conclusion
The SIT-Q-7d appears to be a useful tool for ranking individuals in large-scale observational studies examining total and domain-specific sitting.
doi:10.1249/MSS.0000000000000214
PMCID: PMC4047320  PMID: 24492633
SITTING; ADULT; ACCELEROMETER; LOG; POSTURE; PSYCHOMETRIC
18.  Five and Ten Year Follow-up on Intradiscal Ozone Injection for Disc Herniation 
Background
Disc herniation is the most common cause for spinal surgery and many clinicians employ epidural steroid injections with limited success. Intradiscal injection of ozone gas has been used as an alternative to epidural steroids and surgical discectomy. Early results are positive but long-term data are limited.
Methods
One hundred and eight patients with confirmed contiguous disc herniation were treated with intradiscal injection of ozone in 2002-2003. One-hundred seven patients were available for telephone follow-up at 5 years. Sixty patients were available for a similar telephone follow-up at ten years. Patients were asked to describe their clinical outcome since the injection. Surgical events were documented. MRI images were reviewed to assess the reduction in disc herniation at six months.
Results
MRI films demonstrated a consistent reduction in the size of the disc herniation. Seventy-nine percent of patients had a reduction in herniation volume and the average reduction was 56%. There were 19 patients that ultimately had surgery and 12 of them occurred in the first six months after injection. One of these 12 was due to surgery at another level. Two surgeries involved an interspinous spacer indicated by stenosis or DDD. All other surgeries were discectomies. Of the patients that avoided surgery 82% were improved at 5 years and 88% were improved at 10 years. Other than subsequent surgeries, no spine-related complications were experienced.
Conclusions/Level of Evidence
We conclude that ozone is safe and effective in approximately 75% of patients with disc herniation and the benefit is maintained through ten years. This is a retrospective review and randomized trials are needed.
Clinical Relevance
Intradiscal ozone injection may enable patients to address their pain without multiple epidural injections and surgery. The benefit of ozone is durable and does not preclude future surgical options. The risk reward profile for this treatment is favorable.
doi:10.14444/1017
PMCID: PMC4325503
19.  Comparison of Two Methods of Epidural Steroid Injection in the Treatment of Recurrent Lumbar Disc Herniation 
Asian Spine Journal  2014;8(5):646-652.
Study Design
Prospective study.
Purpose
We compared the effects of two methods of epidural steroid injection in patients with recurrent disc herniation.
Overview of Literature
To our knowledge, there is no previous report of such a comparison in these patients.
Methods
The study was performed with 30 patients with relapsed lumbar disc herniation whose pain was not relieved by conservative remedies. The patients were divided into two groups, each of 15 patients, and entered the study for caudal or transforaminal injections. The degree of pain, ability to stand and walk, and the Prolo function score were evaluated in both groups before the injection and 2 months and 6 months after the injection.
Results
The degrees of pain reduction in the caudal injection group in the second and sixth months were 0.6 and 1.63, respectively, and in the transforaminal injection group were 1.33 and 1.56, respectively. The difference between the two methods was not statistically significant. Similarly, no other evaluated criterion showed a significant difference between the methods.
Conclusions
In the current study, the caudal and transforaminal steroid injection methods showed similar outcomes in the treatment of relapsed lumbar disc herniation. However, more detailed patient categorizing may help in finding possible subgroups with differences.
doi:10.4184/asj.2014.8.5.646
PMCID: PMC4206815  PMID: 25346818
Lumbar spine; Recurrent disc herniation; Epidural steroid; Caudal; Transforaminal
20.  Children's and adolescents' sedentary behaviour in relation to socioeconomic position 
Background
Sedentary behaviour is an emerging cardiometabolic risk factor in young people. Little is known about how socioeconomic position (SEP) and sedentary behaviour are associated in children and adolescents. This study examines associations between SEP and sedentary behaviour in school-age children and adolescents.
Methods
The core sample comprised 3822 Health Survey for England 2008 participants aged 5–15 years with complete information on SEP (household income, head of household occupational social class and area deprivation) and self-reported sedentary time (television viewing and other sitting during non-school times). Accelerometer-measured total sedentary time was measured in a subsample (N=587). We examined multivariable associations between SEP (including a composite SEP score) and sedentary time using generalised linear models, adjusting for age, sex, body mass index, physical activity, accelerometer wear time and mutually adjusting for the other SEP indicators.
Results
Participants in the highest SEP category spent 16 min/day less (95% CI 6 to 25, p=0.003) watching TV than participants in the lowest SEP category; yet they spent 7 (2 to 16, p=0.010) and 17 (5 to 29, p<0.000) min/day more in non-TV sitting and total (accelerometry-measured) sedentary time, respectively. Associations across individual SEP components varied in strength. Area deprivation was not associated with sedentary time.
Conclusions
Low SEP is linked with higher television times but with lower total (accelerometer-measured) sedentary time, and non-TV sitting during non-school time in children and adolescents. Associations between sedentary time and SEP differ by type of sedentary behaviour. TV viewing is not a good proxy for total sedentary time in children.
doi:10.1136/jech-2013-202609
PMCID: PMC3835391  PMID: 23851152
Physical Activity; Social Inequalities; Health Behaviour
21.  Increase of nerve growth factor levels in the human herniated intervertebral disc: can annular rupture trigger discogenic back pain? 
Arthritis Research & Therapy  2014;16(4):R159.
Introduction
Nerve growth factor (NGF) has an important role in the generation of discogenic pain. We hypothesized that annular rupture is a trigger for discogenic pain through the action of NGF. In this study, the protein levels of NGF in discs from patients with disc herniation were examined and compared with those from discs of patients with other lumbar degenerative disc diseases.
Methods
Patients (n = 55) with lumbar degenerative disc disease treated by surgery were included. Nucleus pulposus tissue (or herniated disc tissue) was surgically removed and homogenized; protein levels were quantified using an enzyme-linked immunosorbent assay (ELISA) for NGF. Levels of NGF in the discs were compared between 1) patients with herniated discs (herniated group) and those with other lumbar degenerative disc diseases (non-herniated group), and 2) low-grade and high-grade degenerated discs. Patient’s symptoms were assessed using a visual analog scale (VAS) and the Oswestry disability index (ODI); the influence of NGF levels on pre- and post-operative symptoms was examined.
Results
Mean levels of NGF in discs of patients were significantly higher in herniated discs (83.4 pg/mg total protein) than those in non-herniated discs (68.4 pg/mg).
No significant differences in levels of NGF were found between low-grade and high-grade degenerated discs. Multivariate analysis, adjusted for age and sex, also showed significant correlation between the presence of disc herniation and NGF levels, though no significant correlation was found between disc degeneration and NGF levels. In both herniated and non-herniated groups, pre-operative symptoms were not related to NGF levels. In the herniated group, post-operative lower extremity pain and low back pain (LBP) in motion were greater in patients with low levels of NGF; no significant differences were found in the non-herniated group.
Conclusions
This study reports that NGF increased in herniated discs, and may play an important role in the generation of discogenic pain. Analysis of patient symptoms revealed that pre-operative NGF levels were related to post-operative residual lower extremity pain and LBP in motion. The results suggest that NGF in the disc is related to pain generation, however, the impact of NGF on generation of LBP varies in individual patients.
Electronic supplementary material
The online version of this article (doi:10.1186/ar4674) contains supplementary material, which is available to authorized users.
doi:10.1186/ar4674
PMCID: PMC4261264  PMID: 25069717
22.  Non-alcoholic fatty liver disease is associated with higher levels of objectively measured sedentary behaviour and lower levels of physical activity than matched healthy controls 
Frontline Gastroenterology  2014;6(1):44-51.
Background and aims
Physical activity is a key determinant of metabolic control and is recommended for people with non-alcoholic fatty liver disease (NAFLD), usually alongside weight loss and dietary change. To date, no studies have reported the relationship between objectively measured sedentary behaviour and physical activity, liver fat and metabolic control in people with NAFLD, limiting the potential to target sedentary behaviour in clinical practice. This study determined the level of sedentary behaviour and physical activity in people with NAFLD, and investigated links between physical activity, liver fat and glucose control.
Methods
Sedentary behaviour, physical activity and energy expenditure were assessed in 37 adults with NAFLD using a validated multisensor array over 7 days. Liver fat and glucose control were assessed, respectively, by 1H-MRS and fasting blood samples. Patterns of sedentary behaviour were assessed by power law analyses of the lengths of sedentary bouts fitted from raw sedentary data. An age and sex-matched healthy control group wore the activity monitor for the same time period.
Results
People with NAFLD spent approximately half an hour extra a day being sedentary (1318±68 vs1289±60 mins/day; p<0.05) and walked 18% fewer steps (8483±2926 vs 10377±3529 steps/day; p<0.01). As a consequence, active energy expenditure was reduced by 40% (432±258 vs 732±345 kcal/day; p<0.01) and total energy expenditure was lower in NAFLD (2690±440 vs 2901±511 kcal/day; p<0.01). Power law analyses of the lengths of sedentary bouts demonstrated that patients with NAFLD also have a lower number of transitions from being sedentary to active compared with controls (13±0.03 vs15±0.03%; p<0.05).
Conclusions
People with NAFLD spend more time sedentary and undertake less physical activity on a daily basis than healthy controls. High levels of sedentary behaviour and low levels of physical activity represent a therapeutic target that may prevent progression of metabolic conditions and weight gain in people with NAFLD and should be considered in clinical care.
doi:10.1136/flgastro-2014-100432
PMCID: PMC4283712  PMID: 25580206
FATTY LIVER; NONALCOHOLIC STEATOHEPATITIS; OBESITY
23.  Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae? 
European Spine Journal  2013;22(4):690-696.
Purpose
To investigate the prevalence of infected herniated nucleus material in lumbar disc herniations and to determine if patients with an anaerobic infected disc are more likely to develop Modic change (MC) (bone oedema) in the adjacent vertebrae after the disc herniation. MCs (bone oedema) in vertebrae are observed in 6 % of the general population and in 35–40 % of people with low back pain. These changes are strongly associated with low back pain. There are probably a mechanical cause and an infective cause that causes MC. Several studies on nuclear tissue from herniated discs have demonstrated the presence of low virulent anaerobic microorganisms, predominantly Propionibacterium acnes, in 7–53 % of patients. At the time of a herniation these low virulent anaerobic bacteria may enter the disc and give rise to an insidious infection. Local inflammation in the adjacent bone may be a secondary effect due to cytokine and propionic acid production.
Methods
Patients undergoing primary surgery at a single spinal level for lumbar disc herniation with an MRI-confirmed lumbar disc herniation, where the annular fibres were penetrated by visible nuclear tissue, had the nucleus material removed. Stringent antiseptic sterile protocols were followed.
Results
Sixty-one patients were included, mean age 46.4 years (SD 9.7), 27 % female. All patients were immunocompetent. No patient had received a previous epidural steroid injection or undergone previous back surgery. In total, microbiological cultures were positive in 28 (46 %) patients. Anaerobic cultures were positive in 26 (43 %) patients, and of these 4 (7 %) had dual microbial infections, containing both one aerobic and one anaerobic culture. No tissue specimens had more than two types of bacteria identified. Two (3 %) cultures only had aerobic bacteria isolated.
In the discs with a nucleus with anaerobic bacteria, 80 % developed new MC in the vertebrae adjacent to the previous disc herniation. In contrast, none of those with aerobic bacteria and only 44 % of patients with negative cultures developed new MC. The association between an anaerobic culture and new MCs is highly statistically significant (P = 0.0038), with an odds ratio of 5.60 (95 % CI 1.51–21.95).
Conclusion
These findings support the theory that the occurrence of MCs Type 1 in the vertebrae adjacent to a previously herniated disc may be due to oedema surrounding an infected disc. The discs infected with anaerobic bacteria were more likely (P < 0.0038) to develop MCs in the adjacent vertebrae than those in which no bacteria were found or those in which aerobic bacteria were found.
doi:10.1007/s00586-013-2674-z
PMCID: PMC3631023  PMID: 23397187
Bacterial infection; Modic changes; Endplate changes; Propionibacterium acnes; Lumbar disc herniation
24.  Prolonged sedentary time and physical activity in workplace and non-work contexts: a cross-sectional study of office, customer service and call centre employees 
Background
To examine sedentary time, prolonged sedentary bouts and physical activity in Australian employees from different workplace settings, within work and non-work contexts.
Methods
A convenience sample of 193 employees working in offices (131), call centres (36) and customer service (26) was recruited. Actigraph GT1M accelerometers were used to derive percentages of time spent sedentary (<100 counts per minute; cpm), in prolonged sedentary bouts (≥20 minutes or ≥30 minutes), light-intensity activity (100–1951 cpm) and moderate-to-vigorous physical activity (MVPA; ≥1952 cpm). Using mixed models adjusted for confounders, these were compared for: work days versus non-work days; work hours versus non-work hours (work days only); and, across workplace settings.
Results
Working hours were mostly spent sedentary (77.0%, 95%CI: 76.3, 77.6), with approximately half of this time accumulated in prolonged bouts of 20 minutes or more. There were significant (p<0.05) differences in all outcomes between workdays and non-work days, and, on workdays, between work- versus non-work hours. Results consistently showed “work” was more sedentary and had less light-intensity activity, than “non-work”. The period immediately after work appeared important for MVPA. There were significant (p<0.05) differences in all sedentary and activity outcomes occurring during work hours across the workplace settings. Call-centre workers were generally the most sedentary and least physically active at work; customer service workers were typically the least sedentary and the most active at work.
Conclusion
The workplace is a key setting for prolonged sedentary time, especially for some occupational groups, and the potential health risk burden attached requires investigation. Future workplace regulations and health promotion initiatives for sedentary occupations to reduce prolonged sitting time should be considered.
doi:10.1186/1479-5868-9-128
PMCID: PMC3546308  PMID: 23101767
Occupational sitting; Active time; Workers; Leisure-time
25.  Fluoroscopic lumbar interlaminar epidural injections in managing chronic lumbar axial or discogenic pain 
Journal of Pain Research  2012;5:301-311.
Among the multiple causes of chronic low back pain, axial and discogenic pain are common. Various modalities of treatments are utilized in managing discogenic and axial low back pain including epidural injections. However, there is a paucity of evidence regarding the effectiveness, indications, and medical necessity of any treatment modality utilized for managing axial or discogenic pain, including epidural injections. In an interventional pain management practice in the US, a randomized, double-blind, active control trial was conducted. The objective was to assess the effectiveness of lumbar interlaminar epidural injections of local anesthetic with or without steroids for managing chronic low back pain of discogenic origin. However, disc herniation, radiculitis, facet joint pain, or sacroiliac joint pain were excluded. Two groups of patients were studied, with 60 patients in each group receiving either local anesthetic only or local anesthetic mixed with non-particulate betamethasone. Primary outcome measures included the pain relief-assessed by numeric rating scale of pain and functional status assessed by the, Oswestry Disability Index, Secondary outcome measurements included employment status, and opioid intake. Significant improvement or success was defined as at least a 50% decrease in pain and disability. Significant improvement was seen in 77% of the patients in Group I and 67% of the patients in Group II. In the successful groups (those with at least 3 weeks of relief with the first two procedures), the improvement was 84% in Group I and 71% in Group II. For those with chronic function-limiting low back pain refractory to conservative management, it is concluded that lumbar interlaminar epidural injections of local anesthetic with or without steroids may be an effective modality for managing chronic axial or discogenic pain. This treatment appears to be effective for those who have had facet joints as well as sacroiliac joints eliminated as the pain source.
doi:10.2147/JPR.S32699
PMCID: PMC3442746  PMID: 23055773
lumbar disc herniation; axial or discogenic pain; lumbar interlaminar epidural injections; local anesthetic; steroids; controlled comparative local anesthetic blocks; NCT00681447

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