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EFFICACY OF INTRAVENOUS METHYLPREDNISOLONE
ON SCIATIC PAIN
STEPHEN J. LIPSON, MD, KATHERINE TAFT, MSN, RNC, SONU AHLUWALIA, MD
DEPARTMENT OF ORTHOPAEDIC SURGERY, BETH ISRAEL DEACONESS MEDICAL CENTER*
follow-up data. Pain was registered on a 0-10 visual analogue
Sciatica clinically occurs in 4-6% of the U.S. population.1
Herniated lumbar intervertebral disk and spinal stenosis are
the common causes of sciatica. Sciatica leads to impairment
Patients ranged in age from 29 to 92 years. Twenty-four
which accounts for significant medical attention and cost
patients (40%) were male. Pain relief was noted in 80% of
with the use of a range of responses including rest which
patients, of which 60% had marked relief, 15% moderate, and
may require hospitalization because of incapacitation, opiate
25% mild relief. Of those with relief, 75% had recurrence of
analgesics, non-steroidal antiinflammatory drugs, physical
pain. 63% noted relief within 24 hours of treatment. The most
therapy, lumbar epidural steroid injection, and ultimately
common side effects were a transient metallic taste during
surgery if the pain and impairment does not resolve through
infusion and transient sleep disturbance on the night following
natural history and is not mandated by cauda equina syndrome
or progressive neurologic deficit. The goal of evaluation and
management is to provide pain relief and minimize disability.
The history of sciatica and the ruptured lumbar interverte-
The primary care physician often is the first point of
bral herniated disk has long been an interest of clinical research
patient contact and the orthopaedic surgeon may be consulted.
clinically in the Harvard orthopaedic community, particularly
We conducted an observational investigation of the role of an
at MGH.3 We have been interested in the pathophysiology of
intravenous (i.v.) methylprednisolone protocol in the manage-
the herniated disk and examined alternative concepts of its
ment of acute sciatica caused by herniated lumbar interverte-
formation and pathophysiology.4 The fundamental objectives of
bral disk and degenerative spinal stenosis.
a musculoskeletal operation is to relieve pain, reduce deformity,
and improve function. At the area of the lumbar spine, the
Sixty patients with acute sciatica were enrolled in the study
surgery focuses on decompression and stabilization through
on the basis of a clinical diagnosis made solely on the criteria
arthrodesis. Mixter was concerned over the over-utilization and
of history and physical examination. Radiculopathy and/or root
complications of lumbar diskectomy for the management of
tension signs, especially the bowstring test,2 were used as the
low back pain and sciatica.5 These concerns are current to this
signs for including patients in the study. Methylprednisolone,
day and have increased because of the socioeconomic issues
1 gram diluted in 250ml of normal saline, administered i.v.
of technologies increasing in utilization and fiscal cost, while
over 1.5 hours, was used in all patients. The method was
the concepts of care are redefined from the traditional medical
on the basis of a standard protocol utilized in the treatment
concern directed toward the individual patient struck with
of multiple sclerosis. Patients were examined at the time of
pain and suffering to concern for the cost effectiveness of
presentation and follow-up. Informed consent was obtained
an intervention and the “bottomline” outcome to the entire
prior to treatment. Telephone interviews were used to obtain
medical delivery system. These contemporary conflicts are discussed on a daily basis in our communities, hospitals, and
Stephen J. Lipson, MD is a Clinical Professor in Orthopaedic Surgery at Harvard
medical schools. It is a continuing interest at Harvard Medical
School where teaching medicine as well as the agenda of
Katherine Taft, MSN, RNC is a Staff Nurse Practitioner, Beth Israel Deaconess
medical technology and the concepts of ethics and caring are
Sonu S. Ahluwalia, MD is a Clinical Fellow in Orthopaedic Surgery at Harvard
It is within these contemporary challenges that we under-
took this study of a common clinical condition, sciatica. The
method provides some insight into the evaluation and manage-ment of sciatica and addresses an alternative of acute care
based upon the simplicity of history and physical examination.
It provides medical students with a mixture of differential diag-
noses and analytical thinking while providing traditional care
*The authors are pleased to announce that this study will be presented at the
cost effectively to the patient, provider, and the infrastructure
International Society for the Study of the Lumbar Spine meeting as a poster
Methylprednisolone i.v. can provide transient relief of
of the underlying disorder. The protocol is simple, easy to
acute sciatica. It can be administered solely on the basis of a
administer, and is known to be free of the complications
clinical diagnosis made by history and physical examination.
associated with prolonged use of corticosteroids. Although not
Pain tends to recur within days so that the use of this
a cure for the underlying disorder, the protocol can provide an
intervention is considered short term and is easily done in an
effective acute response providing relief to both the patient and
ambulatory setting in order to allow the continued activity of
the provider who is confronted with the problem of what to
the patient, the avoidance of narcotics with their adverse side
do with his or her patient who has acute pain and impairment
effects, and acute hospitalization which contributes to cost
requiring a timely response. Further research including a
and prolonged impairment. Follow-up lumbar epidural steroid
blinded, prospective cohort study will be of value.
injection is often used for more prolonged non-operative care
1. Frymoyer JW. Lumbar disc disease: epidemiology. Instr Course Lect 1992;41:217-23.
2. MacNab I, McCulloch J. Backache, 2nd ed. Baltimore, MD: Williams & Wilkins, 1990:164-5.
3. Mixter WJ, Barr JS. Rupture of the intervertebral disc with involvement of the spinal canal. N Engl J Med 1934;211:210-5.
4. Lipson SJ. Metaplastic proliferative fibrocartilage as an alternative concept to herniated intervertebral disc. Spine 1988;13:1055-60.
5. Frymoyer JW. Radiculopathies: lumbar disc herniation and recess stenosis. Patient selection, predictors of success and failure, and non-surgical treatment options. In: The
Adult Spine. Principles and Practice. Frymoyer JW, ed. New York: Raven Press, 1991:1719.
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Lebenslauf Name: Ausbildung: St. Gotthard Gymnasium der Benediktiner, Niederalteich, Abitur 1988 Ärztliche Vorprüfung am 03.09.1990 1990- 1994 Friedrich-Alexander-Universität Erlangen-Nürnberg 1. Abschnitt der Ärztlichen Prüfung am 29.08.1991 2. Abschnitt der Ärztlichen Prüfung am 22.03.1994 1994 - 1995 Universität Regensburg 3. Abschnitt der Ärztlichen Prüfung am 04.05.1