van Helvoirt Hans, Apeldoorn Adri T, Ostelo Raymond W, Knol Dirk L, Arts Mark P, Kamper Steven J, van Tulder Maurits W
Medical Back Neck Centre, The Hague and Rugpoli Brabant Tilburg, The Netherlands.
Pain Med. 2014 Jul;15(7):1100-8. doi: 10.1111/pme.12450. Epub 2014 May 7.
Prospective cohort study.
To report the clinical course of patients with MRI-confirmed lumbar disc herniation-related radicular noncentralizing pain who received transforaminal epidural steroid injections (TESIs) and mechanical diagnosis and therapy (MDT).
Noncentralizing symptoms in patients with lumbar disc herniation are associated with poor outcome. Commonly used treatments for these patients include TESIs and MDT. No study has evaluated the outcome of combining both strategies.
Consecutive candidates for herniated lumbar disc surgery with noncentralizing chronic pain were eligible. Patients received TESIs followed by MDT. The primary outcomes were pain severity in the leg, disability (Roland-Morris Disability Questionnaire for Sciatica), and global perceived effect (GPE). Outcomes were measured at baseline, discharge, and 12 months. Linear mixed-models and McNemar's tests were used to analyze outcome data.
Sixty-nine patients receive TESIs. After TESIs, symptoms were resolved completely in 11 patients (16%). In these patients, symptom resolution was maintained at 12 months. A second subgroup of 32 patients (46%) reported significantly less pain after TESIs and showed centralization with MDT reassessment (significant reductions in leg pain and disability [P < 0.001]) and a satisfaction rate of 90% at 12 months. A third subgroup of 11 patients (16%) reported significantly less pain after TESIs but still showed noncentralization with MDT reassessment (significant reductions in leg pain and disability [P < 0.05] and a satisfaction rate of 50% at 12 months). A fourth subgroup of 15 patients (22%) did not respond on TESIs and received an operative intervention.
The results indicate that a course of TESIs followed by MDT may be able to avoid surgery in a substantial proportion of candidates for herniated lumbar disc surgery.
前瞻性队列研究。
报告经磁共振成像（MRI）确诊为腰椎间盘突出症相关神经根性非中央化疼痛的患者接受经椎间孔硬膜外类固醇注射（TESIs）和机械诊断与治疗（MDT）后的临床病程。
腰椎间盘突出症患者的非中央化症状与预后不良相关。这些患者常用的治疗方法包括TESIs和MDT。尚无研究评估联合这两种策略的疗效。
连续入选的有非中央化慢性疼痛的腰椎间盘突出症手术候选患者符合条件。患者先接受TESIs，然后接受MDT。主要结局指标为腿部疼痛严重程度、残疾程度（坐骨神经痛的罗兰 - 莫里斯残疾问卷）和总体感知效果（GPE）。在基线、出院时和12个月时测量结局指标。采用线性混合模型和麦克尼马尔检验分析结局数据。
69例患者接受了TESIs。接受TESIs后，11例患者（16%）症状完全缓解。在这些患者中，症状缓解在12个月时得以维持。第二组32例患者（46%）在接受TESIs后疼痛明显减轻，经MDT重新评估显示症状中央化（腿部疼痛和残疾程度显著降低[P < 0.001]），12个月时满意度为90%。第三组11例患者（16%）在接受TESIs后疼痛明显减轻，但经MDT重新评估仍显示非中央化（腿部疼痛和残疾程度显著降低[P < 0.05]），12个月时满意度为50%。第四组15例患者（22%）对TESIs无反应，接受了手术干预。
结果表明，先进行TESIs疗程然后进行MDT，可能能够使相当一部分腰椎间盘突出症手术候选患者避免手术。
