Sciatica Ropper, Allan H; Zafonte, Ross D
The New England journal of medicine,
03/2015, Volume:
372, Issue:
13
Journal Article
Peer reviewed
Pain that extends from the buttock down the course of the sciatic nerve is common. Nearly 85% of cases are associated with a disk disorder. The causes, assessment, and management of sciatica are ...discussed.
The mundane malady sciatica has been known to physicians since antiquity.
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It is pain that radiates from the buttock downward along the course of the sciatic nerve,
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but the term has been used indiscriminately for a variety of back and leg symptoms. Although sciatica has several causes, Mixter and Barr extended previous observations to establish in 1934 that the principal source is compression of a lumbar nerve root by disk material that has ruptured through its surrounding annulus (see the Glossary).
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Neuroradiologic studies affirm that 85% of cases of sciatica are associated with a disk disorder.
4
Anatomy of the Sciatic . . .
To characterize the functional impairments of a cohort of patients undergoing inpatient rehabilitation after surviving severe COVID-19 illness, in order to better understand the ongoing needs of this ...patient population.
This study consisted of a retrospective chart review of consecutive patients hospitalized for COVID-19 and admitted to a regional inpatient rehabilitation hospital from April 29th to May 22nd, 2020. Patient demographics, clinical characteristics and complications from acute hospitalization were examined. Measures of fall risk (Berg Balance Scale), endurance (6 Minute Walk Test), gait speed (10 Meter Walk Test), mobility (transfer and ambulation independence), cognition, speech and swallowing (American Speech and Hearing Association National Outcomes Measurement System Functional Communication Measures) were assessed at rehabilitation admission and discharge.
The study population included 29 patients and was 70% male, 58.6% white and with a mean age of 59.5. The mean length of acute hospitalization was 32.2 days with a mean of 18.7 days intubated. Patients spent a mean of 16.7 days in inpatient rehabilitation and 90% were discharged home. Patients demonstrated significant improvement from admission to discharge in measures of fall risk, endurance, gait speed, mobility, cognition, speech and swallowing, (p< 0.05). At discharge, a significant portion of the population continued to deficits in cognition (attention 37%; memory 28%; problem solving 28%), balance (55%) and gait speed (97%).
Patients admitted to inpatient rehabilitation after hospitalization with COVID-19 demonstrated deficits in mobility, cognition, speech and swallowing at admission and improved significantly in all of these domains by discharge. However, a significant number of patients exhibited residual deficits at discharge highlighting the post-acute care needs of this patient population.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
...recent progress in characterising specific consequences and the availability of longitudinal studies of outcomes are providing the basis for improved understanding of TBI sequelae, as highlighted ...in two Series papers on TBI in The Lancet Neurology.1,2 Meyfroidt and colleagues1 have focused on the puzzling clinical syndrome of paroxysmal sympathetic hyperactivity (PSH), a specific consequence of severe brain injury, especially TBI, that can last for weeks to months after injury, while Wilson and colleagues2 have reviewed the growing body of evidence emphasising that TBI should be viewed as a chronic health condition with lifelong consequences for many patients. ...there is a wide range in reported incidences of PSH; a further challenge to efforts to understand the epidemiology of PSH is that, for many patients, symptoms are unmasked only when analgesics are stopped upon transfer from an intensive care unit (ICU) to a rehabilitation setting. The recent proposal of an excitatory:inhibitory ratio model might add a construct from which to investigate this dysfunction physiologically.5 Few randomised controlled trials of interventions for PSH exist, and treatment decisions are largely based on clinical experience. ...several medications proposed to treat PSH, reported in case series, such as opioids and α2-adrenergic drugs,1 might have sedative effects and therefore affect progress if used in the rehabilitation setting. Most worrisome is the growing recognition that CTE could be the result of subconcussive blows and is not solely linked to clinically apparent concussions. ...population-wide effects on outcome are unclear but concerning.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Pharmacological management of neurobehavioral disorders following traumatic brain injury (TBI) is common practice. However, the evidence available to guide this practice remains sparse. This review ...summarizes, in brief, the state of knowledge, organized via a time continuum from injury as well as by symptom complex. The areas of neuroprotection, hypo-arousal, attention and memory deficits, aggression, agitation, depression, and mania are reviewed. The literature was searched with PubMed on the terms "traumatic brain injury" or "brain injury" with "pharmacology" (and the symptoms according to which this review is arranged). Additional searches were conducted with the specific symptoms as search terms, crossed with the therapeutic agents or drug classes discussed. Where a paucity of prospective data exists, case reports and retrospective studies are included. Studies to date have yielded minimal positive evidence for enhancing function, memory, and behavior after TBI. No single agent likely will become sentinel in the recovery process, and combination therapy in the acute and postacute settings are required. A need exists to further define the role of psychopharmacology in postacute TBI medicine and the specific characteristics of subpopulations who might benefit.
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DOBA, FSPLJ, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
IMPORTANCE: Traumatic brain injury (TBI) leads to 2.9 million visits to US emergency departments annually and frequently involves a disorder of consciousness (DOC). Early treatment, including ...withdrawal of life-sustaining therapies and rehabilitation, is often predicated on the assumed worse outcome of disrupted consciousness. OBJECTIVE: To quantify the loss of consciousness, factors associated with recovery, and return to functional independence in a 31-year sample of patients with moderate or severe brain trauma. DESIGN, SETTING, AND PARTICIPANTS: This cohort study analyzed patients with TBI who were enrolled in the Traumatic Brain Injury Model Systems National Database, a prospective, multiyear, longitudinal database. Patients were survivors of moderate or severe TBI who were discharged from acute hospitalization and admitted to inpatient rehabilitation from January 4, 1989, to June 19, 2019, at 1 of 23 inpatient rehabilitation centers that participated in the Traumatic Brain Injury Model Systems program. Follow-up for the study was through completion of inpatient rehabilitation. EXPOSURES: Traumatic brain injury. MAIN OUTCOMES AND MEASURES: Outcome measures were Glasgow Coma Scale in the emergency department, Disability Rating Scale, posttraumatic amnesia, and Functional Independence Measure. Patient-related data included demographic characteristics, injury cause, and brain computed tomography findings. RESULTS: The 17 470 patients with TBI analyzed in this study had a median (interquartile range IQR) age at injury of 39 (25-56) years and included 12 854 male individuals (74%). Of these patients, 7547 (57%) experienced initial loss of consciousness, which persisted to rehabilitation in 2058 patients (12%). Those with persisting DOC were younger; had more high-velocity injuries; had intracranial mass effect, intraventricular hemorrhage, and subcortical contusion; and had longer acute care than patients without DOC. Eighty-two percent (n = 1674) of comatose patients recovered consciousness during inpatient rehabilitation. In a multivariable analysis, the factors associated with consciousness recovery were absence of intraventricular hemorrhage (adjusted odds ratio OR, 0.678; 95% CI, 0.532-0.863; P = .002) and intracranial mass effect (adjusted OR, 0.759; 95% CI, 0.595-0.968; P = .03). Functional improvement (change in total functional independence score from admission to discharge) was +43 for patients with DOC and +37 for those without DOC (P = .002), and 803 of 2013 patients with DOC (40%) became partially or fully independent. Younger age, male sex, and absence of intraventricular hemorrhage, intracranial mass effect, and subcortical contusion were associated with better functional outcome. Findings were consistent across the 3 decades of the database. CONCLUSIONS AND RELEVANCE: This study found that DOC occurred initially in most patients with TBI and persisted in some patients after rehabilitation, but most patients with persisting DOC recovered consciousness during rehabilitation. This recovery trajectory may inform acute and rehabilitation treatment decisions and suggests caution is warranted in consideration of withdrawing or withholding care in patients with TBI and DOC.
Background Estimates of the number of firearm-related injuries widely vary. Although focus has been primarily on deaths, the societal cost of caring for victims of these injuries is largely unknown. ...Our goal was to estimate the economic impact of nonfatal, firearm-related injuries in the United States based on recent, publically available data. Methods We queried several national registries for hospital and emergency department (ED) discharges from 2006 to 2010 to estimate the annual incidence of firearm-related injuries. The cost of direct medical services and lost productivity from firearm-related injuries were extrapolated from recently published estimates. To identify potentially important trends, we compared the economic impact and payor mix for firearm-related injuries in 2006 with those in 2010. Results During the 5-year analytic period, we identified 385,769 (SE = 29,328) firearm-related ED visits resulting in 141,914 (SE = 14,243) hospital admissions, costing more than $88 billion (SE = $8.0 billion). Between 2006 and 2010, there was a decrease in the rate of hospital visits from 6.65 per 10,000 visits in 2006 to 5.76 per 10,000 visits in 2010 ( P < .001). Similarly, the rate of hospital admissions and ED visits without admission decreased from 2.58 per 10,000 to 1.96 per 10,000 ( P < .001) and 4.08 per 10,000 to 3.79 per 10,000 ( P < .001). Regression of the economic costs from 2006 to 2010, adjusted for Consumer Price Index, showed no change ( P = .15). There was a decrease in the proportion of Uninsured between 2006 and 2010 from 51.6% to 46.78% ( P < .001). Conclusion Firearm-related injuries are a major economic burden to not only the American health care system but also to American society. The incidence of these injuries has decreased slightly from 2006 to 2010, with no change in the economic burden. Research aimed at understanding the associated financial, social, health, and disability-related issues related to firearm injuries is necessary and would likely enhance our knowledge of the causes of these events, and may accelerate development of interventions and policies to decrease the staggering medical and societal cost of gun violence.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background:
Former American football players have a higher prevalence of cognitive impairment than that of the US general population. It remains unknown what aspects of playing football are ...associated with neuropsychiatric outcomes.
Hypothesis:
It was hypothesized that seasons of professional football, playing position, and experience of concussions were associated with cognition-related quality of life (QOL) and indicators of depression and anxiety.
Study Design:
Descriptive epidemiology study.
Methods:
The authors examined whether seasons of professional football, playing position, and experience of concussions, as measured by self-report of 10 symptoms, were associated with cognition-related QOL and indicators of depression and anxiety in a cross-sectional survey conducted 2015 to 2017. Cognition-related QOL was measured by the short form of the Quality of Life in Neurological Disorders: Applied Cognition–General Concerns. The Patient Health Questionnaire–4 measured depression and anxiety symptoms. Of 13,720 eligible men with apparently valid contact information, 3506 players returned a questionnaire at the time of this analysis (response rate = 25.6%).
Results:
Seasons of professional play (risk ratio RR per 5 seasons = 1.19, 95% CI = 1.06-1.34) and playing position were associated with cognition-related QOL. Each 5 seasons of play was associated with 9% increased risk of indicators of depression at borderline statistical significance (P = .05). When compared with former kickers, punters, and quarterbacks, men who played any other position had a higher risk of poor cognition-related QOL, depression, and anxiety. Concussion symptoms were strongly associated with poor cognition-related QOL (highest concussion quartile, RR = 22.3, P < .001), depression (highest quartile, RR = 6.0, P < .0001), and anxiety (highest quartile, RR = 6.4, P < .0001), even 20 years after last professional play.
Conclusion:
The data suggest that seasons of play and playing position in the NFL are associated with lasting neuropsychiatric health deficits. Additionally, poor cognition-related QOL, depression, and anxiety appear to be associated with concussion in the long term.
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FSPLJ, NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
This comprehensive review discusses clinical studies of patients following brain injuries (traumatic, acquired, or stroke), who have been treated with amantadine or memantine. Both amantadine and ...memantine are commonly used in the acute rehabilitation setting following brain injuries, despite their lack of FDA-approval for neuro-recovery. Given the broad utilization of such agents, there is a need to review the evidence supporting this common off-label prescribing. The purpose of this review is to describe the mechanisms of action for memantine and amantadine, as well as to complete a comprehensive review of the clinical uses of these agents. We included 119 original, clinical research articles from NCBI Medline, published before 2019. We focused on the domains of neuroplasticity, functional recovery, motor recovery, arousal, fatigue, insomnia, behavior, agitation, and cognition. Most of the existing research supporting the use of amantadine and memantine in recovery from brain injuries was done in very small populations, limiting the significance of conclusions. While most studies are positive; small effect sizes are usually reported, or populations are subject to bias. Furthermore, evidence is so limited that this review includes research regarding both acute and chronic acquired brain injury populations. Fortunately, reported short-term side effects generally are modest, and stop soon after amantadine/memantine is discontinued. However, responses are inconsistent, and the phenotype of responders remains elusive.
This pilot, open-protocol study examined whether scalp application of red and near-infrared (NIR) light-emitting diodes (LED) could improve cognition in patients with chronic, mild traumatic brain ...injury (mTBI). Application of red/NIR light improves mitochondrial function (especially in hypoxic/compromised cells) promoting increased adenosine triphosphate (ATP) important for cellular metabolism. Nitric oxide is released locally, increasing regional cerebral blood flow. LED therapy is noninvasive, painless, and non-thermal (cleared by the United States Food and Drug Administration FDA, an insignificant risk device). Eleven chronic, mTBI participants (26-62 years of age, 6 males) with nonpenetrating brain injury and persistent cognitive dysfunction were treated for 18 outpatient sessions (Monday, Wednesday, Friday, for 6 weeks), starting at 10 months to 8 years post- mTBI (motor vehicle accident MVA or sports-related; and one participant, improvised explosive device IED blast injury). Four had a history of multiple concussions. Each LED cluster head (5.35 cm diameter, 500 mW, 22.2 mW/cm(2)) was applied for 10 min to each of 11 scalp placements (13 J/cm(2)). LEDs were placed on the midline from front-to-back hairline; and bilaterally on frontal, parietal, and temporal areas. Neuropsychological testing was performed pre-LED, and at 1 week, and 1 and 2 months after the 18th treatment. A significant linear trend was observed for the effect of LED treatment over time for the Stroop test for Executive Function, Trial 3 inhibition (p=0.004); Stroop, Trial 4 inhibition switching (p=0.003); California Verbal Learning Test (CVLT)-II, Total Trials 1-5 (p=0.003); and CVLT-II, Long Delay Free Recall (p=0.006). Participants reported improved sleep, and fewer post-traumatic stress disorder (PTSD) symptoms, if present. Participants and family reported better ability to perform social, interpersonal, and occupational functions. These open-protocol data suggest that placebo-controlled studies are warranted.
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