Hoj 200117


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 DISCUSSION
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 References
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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