Anterior Thigh Pain Research Articles

An Institutional Six-year Trend Analysis of the Neurological Outcome After Lateral Lumbar Interbody Fusion

Retrospective case series. To evaluate the proportional trend over time of neurological deficits after lateral lumbar interbody fusion (LLIF) at a single institution. Because lumbar nerve roots converge to run as the lumbar plexus within or less frequently underneath the posterior part of the psoas muscle, they are prone to iatrogenic damage during the transpsoas approach in LLIF, and adverse postoperative neurological sequelae remain a major concern. The electronic medical records and office notes of 451 patients who had consecutively undergone LLIF between March 2006 and April 2012 at a single institution were retrospectively reviewed for reports on postoperative neurological deficits. A total of 293 patients (173 females and 120 males) met the study inclusion criteria and were followed postoperatively for a mean period of 15.4 ± 9.2 months (range: 6-53 mo). The number of included patients who underwent LLIF at our institution was 47 in the years 2006 to 2008 (group A), 155 in 2009 to 2010 (group B), and 91 in 2011 to 2012 (group C). Our data indicate a decreasing proportional trend during the past 6 years for postoperative sensory deficits (SDs), motor deficits (MDs), and anterior thigh pain (TP). The decreasing trends were statistically significant for the proportion of SDs in the immediate postoperative setting (P = 0.018) and close to statistically significant for SDs at last follow-up (P = 0.126), TP immediately after surgery (P = 0.098), and TP at last follow-up (P = 0.136). To the authors' best knowledge, this study constitutes the largest series of this sort to date, with regard to both sample size and study period. The present data indicate a decreasing proportional trend over time for SDs, MDs, and anterior TP, which can be considered a representation of an institutional learning curve during a 6-year time period of performing LLIF.

Acute Pain Control Challenges with Buprenorphine/Naloxone Therapy in a Patient with Compartment Syndrome Secondary to McArdle's Disease: A Case Report and Review

We report the first case of non-iatrogentic exertional rhabdomyolysis leading to acute compartment syndrome in a patient with McArdle's disease. We describe considerations of concurrent buprenorphine/naloxone therapy during episodes of severe acute pain. Case report. A 50-year-old male with a history of McArdle's disease, taking buprenorphine/naloxone for chronic pain and opioid dependence, presented to the Emergency Department with severe bilateral anterior thigh pain. Over the following 8 hours, he was given a total of 12 mg of intravenous hydromorphone with minimal pain relief. The decision was made to initiate patient-controlled analgesia (PCA) with hydromorphone started at 0.5 mg as needed with a 15-minute lockout. Subsequently, the patient's anterior thighs were found to be extremely tense. His creatine kinase level rose to 198,688 units/L and compartment pressures were greater than 90 mm Hg bilaterally. The patient was taken for emergent bilateral fasciotomies. The hydromorphone PCA was increased to 0.8 mg as needed with a 15-minute lockout and a basal rate of 0.5 mg/h. The patient's reported pain plateaued at 3/10 intensity 2 days after surgery, and he was transitioned to oxycodone and hydrocodone/acetaminophen. He followed up with his pain management physician 2 months later who restarted suboxone and a buphrenorphine transdermal patch. Buprenorphine/naloxone is being prescribed off-label with increasing frequency for pain management in patients with or without a history of opioid abuse. Severe acute pain is more difficult to control with opioid analgesics in patients taking buprenorphine/naloxone, requiring higher than usual doses. If buprenorphine/naloxone is discontinued to better treat acute pain with other opioids, monitoring for overdose must take place for at least 72 hours.

Solitary Amyloidoma Related to THA

Amyloidoma of soft tissues is rare, and no previously published reports describe it in relation to hip prostheses. This article presents the case of a 78-year-old woman with a medical history of myelodysplasia and mild renal failure who underwent a right-sided metal-on-polyethylene total hip arthroplasty in 2003. She presented to the outpatient clinic with a 1-year history of right anterior thigh pain. On examination, a large proximal anteromedial lump was palpable and was nontender, nonpulsatile, and firm. She had a positive Trendelenburg test but good hip range of motion. Plain radiographs showed signs of osteolysis around the hip prosthesis. Serology showed mildly raised liver function and renal function but a normal erythrocyte sedimentation rate and white blood cell count. Magnetic resonance imaging revealed a large mixed-signal soft tissue mass directly opposing the anterior cortex of the right femur, related to the hip prosthesis, measuring 16×10×7 cm. Associated destruction of the underlying cortex existed. Histological staining of a biopsy of the mass confirmed that the mass contained AL-type amyloid seen in primary amyloidosis. Mean patient age at diagnosis for amyloid tumors of soft tissues is 66 years. By definition, they start as solitary lesions. The types are important: AA type is related to infection and AL type is a primary process. Patients with AL amyloidomas have a poorer prognosis because they have a higher chance of malignancies. Early diagnosis can prevent long-term serious consequences of this condition.

Genitofemoral Nerve Protection During the Lateral Retroperitoneal Transpsoas Approach

The minimally invasive lateral retroperitoneal approach for lumbar fusions is a novel technique with good results, but also with significant sensory and motor complications. To present the early results of a modified surgical technique, in which the psoas muscle is dissected under direct visualization. Thirteen consecutive patients with L4-5 or L3-4 pathology were prospectively followed after being treated using a minimally invasive lateral approach with direct exposure of the psoas muscle before dissection. There were 7 woman and 6 men with a mean age of 52.3 years. Perioperative parameters like operative time, estimated blood loss, and length of stay, were noted. Pain, paresthesia, and motor weakness, as well as any other complications, were evaluated at 2 weeks and 3 months postoperatively. The mean operative time, estimated blood loss, and length of stay were 163 minutes, 126 mL, and 3 days, respectively. One patient exhibited anterior thigh pain and paresthesia at 2 weeks, both of which resolved by 3 months. Two patients experienced superficial wound infections that healed with antibiotics. The genitofemoral nerve was identified and protected in 7 patients; in 4 patients, it had a more posterior anatomic location than expected. The femoral nerve was not exposed or detected in the operative field by neuromonitoring, nor were there any symptoms related to a femoral nerve injury in any patient. Dissection of the psoas muscle under direct visualization during the minimally invasive lateral approach may provide increased safety to the genitofemoral and femoral nerves.

Atypical femoral fractures associated with long-term bisphosphonate use

A 75-year-old woman with osteoporosis presented with a 2-year history of anterior thigh pain that was worse when standing and walking. She had taken alendronate for more than 20 years, which was replaced with annual zoledronic acid infusions for the last 3 years. On examination, she had an antalgic

Metastatic disease masquerading as mechanical low back pain; atypical symptoms which may raise suspicion

Clinicians working in spinal clinics and outpatient settings are faced with the possibility of identifying patients with serious pathology causing back pain. Spinal metastatic disease is the most common serious pathology seen in non-surgical spinal clinics, with breast cancer being the most common cause of spinal metastases in women (Van Goethem et al., 2004). This case report describes the assessment and treatment of a patient presenting with low back pain radiating into the abdomen and bilateral anterior thigh pain, which was metastatic in origin. This case highlights the importance of early diagnosis of metastatic disease, and identifies symptoms that may help to raise the index of suspicion for the clinician.

Perineural Hematoma Following Lumbar Transforaminal Steroid Injection Causing Acute‐on‐Chronic Lumbar Radiculopathy: A Case Report

Transforaminal epidural steroid injections (TFESI) are commonly performed for the treatment of lumbar herniated nucleus pulposus and lumbosacral radiculopathy. Although rare, documented complications including spinal cord infarction, paraparesis, epidural abscess, paraplegia, and epidural hematoma have been reported. Here, we present a case of perineural hematoma affecting the L4 nerve root resulting in progressive acute-on-chronic lumbar radiculopathy following TFESI. A 72-year-old female presented with 3 months of low back and right anterior thigh pain. She subsequently underwent right L3 and L4 TFESI for physical examination findings concordant with radiographic right foraminal stenosis at L3-4 and L4-5 with L3-4 spondylolisthesis. Over the following week, the patient reported progressive right lower extremity weakness, worsening sensory loss, and ambulatory dysfunction. Examination revealed mild L3/4 myotomal weakness, sensory changes, and areflexia at the right patella. A gadolinium-enhanced MRI was ordered, which showed focal abnormal signal with involvement of the right L4-L5 neuroforamina and extending slightly far laterally, consistent with a small hematoma, affecting the L4 nerve root. Within 2 months, her strength and reflexes normalized and sensory loss diminished following medical management. Although extremely rare, perineural or foraminal hematomas may occur as a serious complication of TFESI, even in the setting of a standardized procedure. Hematoma may cause worsening of symptoms in the acute and subacute phase following TFESI. Further investigation into the etiologies of such injuries is warranted and must be added to the considerations of pain physicians performing these procedures.

Patterns of stress distribution at the proximal femur after implantation of a modular neck prosthesis. A biomechanical study

BackgroundModular total hip arthroplasty incorporating a double taper design is an evolution offering potential advantages compared to single head–neck taper or monolithic designs. Changes in femoral offset, neck length or femoral anteversion are expected to alter the strain distribution. MethodsWe therefore analyzed the strain patterns after usage of all types of necks of a modular neck prosthesis, implanted in composite femurs. FindingsThe load distribution presented a repeatable pattern. Anteverted neck combinations resulted in higher stress at the anterior surface, whereas the retroverted ones at the posterior (e.g. at the middle frontal site, stress is 13.63% higher when we shifted from the long neutral neck to the long 15° anteverted neck and at the middle back site 19.73% higher when we shifted from the long neutral to the long 15° retroverted neck). Compressive stress was larger at the calcar region and exacerbated by the use of the varus neck (e.g. at the frontal 1 site stress increased by 44.01% when we used the long 8° varus neck in comparison to the long neutral neck). Anteverted neck combinations resulted in higher strain at the anterior cortex around the tip of the prosthesis. Short necks exhibited lower stress at the femoral shaft and higher at the trans-trochanteric area. InterpretationAnteverted neck combinations could be more prone to anterior thigh pain. Because of the possible risk of adaptive hypertrophy and early mechanical failure due to increased stress, the surgeon should be cautious when using necks with combined characteristics or short necks.

Intraosseous ganglion cyst within the L4 lamina causing spinal stenosis

There are rare reports of intraosseous ganglion cysts in the cervical spine. However, to our knowledge, there are no previous reports of these cysts occurring in the lumbar spine. To report a case of symptomatic lumbar spinal stenosis caused by an intraosseous ganglion cyst of the L4 lamina that communicated with the spinal canal. Case report. An 86-year-old woman was referred to our spine service for a 2-year history of anterior thigh and leg pain. Magnetic resonance imaging revealed a benign-appearing intraosseous cyst in the left L4 lamina communicating with a posterior epidural cyst at L4-L5 causing marked spinal stenosis. The patient was treated successfully with a laminectomy and resection. The patient underwent partial laminectomies of L4 and L5 preserving the interspinous ligaments between L5-S1 and L3-L4. The cyst was removed en bloc without violation of the cyst wall. Histopathologic examination revealed focal myxoid changes without a cellular lining of the cyst wall, confirming the diagnosis of intraosseous ganglion cyst. This is the first report to describe an intraosseous ganglion cyst occurring in the lumbar spine. Although spinal stenosis is commonly a result of degenerative joint or disc disease, it occasionally may result from more obscure causes. This case illustrates a patient with an intraosseous ganglion cyst within the spinal lamina resulting in spinal stenosis, treated successfully with a laminectomy and resection.

Outcome of An Uncemented Hydroxyapatite Coated Hemiarthroplasty for Displaced Femoral Neck Fractures: A Clinical and Radiographic 2-Year Follow-Up Study

Hemiarthroplasty is the preferred treatment for displaced femoral neck fractures (DFNF) in elderly patients. The use of uncemented stems remains controversial and issues regarding inferior fixation in osteoporotic bone, implant-related pain and decreased mobility have discouraged their use. There is limited evidence for the use of modern uncemented femoral stems in the treatment of DFNF, and we wished to investigate the clinical and radiographic performance of an uncemented hydroxyapatite coated hemiarthroplasty at 2-year follow-up. We included 97 consecutive patients who had an uncemented, hydroxyapatite coated hemiarthroplasty (Corail, Depuy) inserted during a 1-year period. Due to unwillingness or cognitive impairment (n = 6) and death before follow-up (n = 44), a total of 47 patients (39 females) with a mean age of 81 years were available. At two year follow-up 38 of 47 patients lived in their own homes and the median New Mobility Score was 6 (range: 2-9). The median Visual Analogue Scale pain score was 0 (range: 0-5) at rest and 0 (range: 0-8) when walking. Patient satisfaction was a score of 9 (range: 2-10) on the VAS. Anterior or lateral thigh pain or groin pain was reported by 15 patients. The EQ-5D index score at follow-up was 0.72 (range: 0.16-1.00) and the EQ-5D Visual Analogue Score was 70 (range: 15-100). There were no signs of implant loosening in any of the 37 hips undergoing radiographic evaluation at follow-up. The results suggest that an uncemented hydroxyapatite coated hemiarthroplasty can be used to treat displaced intracupsular femoral neck fractures with good clinical and radiographic outcomes at short term follow-up.

Synovial cyst of the hip in a patient with rheumatoid arthritis

A 67-year-old woman with rheumatoid arthritis (RA; Steinblocker stage IV, class 4) who had RA onset at 34 years of age had anterior thigh pain, femoral neuropathy and lower abdominal pain. Physical examination showed multidirectional limit of motion, and radiographic examination showed destruction of the hip joint. MRI and arthrography indicated a cystic lesion that communicated with the hip joint. The rheumatoid synovial cyst was removed during total hip arthroplasty. The symptoms were relieved, and the mass was reduced in size.

Treatment of high hip dislocation with a cementless stem combined with a shortening osteotomy

The purpose of this study was to review the clinical and radiographic outcomes and report the major complications in a group of hips with Crowe type IV developmental dysplasia that underwent reconstruction with a cementless total hip arthroplasty and a transverse subtrochanteric shortening osteotomy fixed with locking compression plate and screws. Fifteen consecutive patients (21 hips) who had coxarthrosis secondary to Crowe Group IV developmental dysplasia of the hip were treated with a cementless prosthesis and a transverse subtrochanteric osteotomy fixed with locking compression plates at a mean age of 41. The mean follow-up period was 5 years. The acetabular cup was placed in the position of the anatomical hip center in every patient. Subtrochanteric femoral shortening osteotomy was fixed with plates and screws in all patients. The mean Harris hip score improved from 36.2 ± 9.8 points to 90.8 ± 2.5 points. Trendelenburg sign was positive in seven hips and two patients complained about continuing anterior thigh pain at the final follow-up. There was no infection. No cases of nonunion were encountered. Two patients had dislocation on early postoperative period (15th and 20th postoperative day). Of these patients, femoral head was changed to 28 mm with stem revision in one patient, and one had acetabular component revision with use of constrained acetabular liner. There was one permanent sciatic nerve palsy. One patient had implant related pain during lying laterally. Plate and screws were removed at postoperative 16th month. Cementless total hip arthroplasty combined with subtrochanteric osteotomy for the treatment of patients with Crowe Group IV developmental dysplasia of the hip is an effective technique to reduce the hip to its original acetabular location and restore the rotational deformities. Plate and screw fixation is a viable option for a secure and stable fixation of femoral stem after subtrochanteric osteotomy.

Differential diagnosis and early management of rapidly progressing hip pain in a 59-year-old male

Objective and importanceRapidly progressing degeneration of the hip joint is an uncommon condition presenting to physical therapy. Differential diagnosis can often be difficult, as clinical and radiographic findings do not always coincide leaving clinicians with difficult decision making regarding course of treatment. The purpose of this case report was to describe the differential diagnosis and early management of a patient with rapidly progressing hip pain.Clinical presentationA 59-year-old male with a complicated medical history was referred with a diagnosis of severe bilateral hip osteoarthritis. Clinical presentation of insidious onset, severe bilateral groin and anterior thigh pain with rapid progression of functional decline lead to the differential diagnosis of bilateral avascular necrosis.InterventionThe patient received seven manual physical therapy sessions over the course of one month.ConclusionDuring this time, the patient’s Lower Extremity Functional Scale score worsened from 33 to 21. The persistence of the patient’s painful symptoms and continued functional decline helped determine cessation of manual therapy and referral back to his GP for further diagnostic testing and eventual correct diagnosis. This case highlights the importance of monitoring patient prognosis using outcome measures leading to a change in patient management strategies.

Ehrlichia chaffeensis presenting with bilateral anterior thigh pain (Louria's sign)

Bilateral anterior thigh pain may indicate bacteremia (Louria's Sign). We present a case of Ehrlichiosis due to Ehrlichia chaffeensis whose predominant presenting symptom was localized bilateral anterior thigh pain.

Herniation of Upper Lumbar Disc - Clinical Finding & Surgical Result -

criteria and functional change in the follow up. Results: The prevalence of upper lumbar disc herniations in all disc herniations was 8.8%. Pre-operative manifestations were lower back pain (85.4%), radiating pain (80.5%), sensory deficit (53.7%), motor deficit (53.7%), and depressed knee jerk (65.9%). The positive rate of the femoral stretching test (78.0%) was higher than the straight leg raising test (39.0%). The VAS score changed from preoperative 9.0±0.8 into postoperative 1.4±1.3 points. The operative results were excellent or good in 82.9%. The rate of resuming previous work, including slight modification was 90.2%. Conclusions: Predictable clinical aspects of the upper lumbar disc herniations are anterior thigh pain with lower back pain, variable motor deficit, sensory deficit, depressed knee jerk and the positive femoral nerve stretching test. Through careful examination and radiological evaluations such as MRI, operative treatment can obtain a symptomatic improvement and satisfactory results.

It's Not All in Your Head

A 63-year-old man presented to the emergency department with shaking chills and drenching sweats of 4 days' duration. He reported no weight loss, arthralgias, headache, visual changes, or new skin eruptions, but he had progressively worsening bilateral anterior thigh pain of 10 days' duration.

Minimally invasive lateral lumbar interbody fusion and transpsoas approach–related morbidity

Recently, the minimally invasive, lateral retroperitoneal, transpsoas approach to the thoracolumbar spinal column has been described by various authors. This is known as the minimally invasive lateral lumbar interbody fusion. The purpose of this study is to elucidate the approach-related morbidity associated with the minimally invasive transpsoas approach to the lumbar spine. To date, there have been only a couple of reports regarding the morbidity of the transpsoas muscle approach. A nonrandomized, prospective study utilizing a self-reported patient questionnaire was conducted between January 2006 and June 2008 at Northwestern University. Data were collected in 53 patients with a follow-up period ranging from 6 months to 3.5 years. Only 2 patients were lost to follow-up. Thirty-six percent (19 of 53) of patients reported subjective hip flexor weakness, 25% (13 of 53) anterior thigh numbness, and 23% (12 of 53) anterior thigh pain. However, 84% of the 19 patients reported complete resolution of their subjective hip flexor weakness by 6 months, and most experienced improved strength by 8 weeks. Of those reporting anterior thigh numbness and pain, 69% and 75% improved to their baseline function by the 6-month follow-up evaluations, respectively. All patients with self-reported subjective hip flexor weakness underwent examinations during subsequent clinic visits after surgery; however, these examinations did not confirm a motor deficit less than Grade 5. Subset analysis showed that the L3-4 and L4-5 levels were most often affected. The minimally invasive, transpsoas muscle approach to the lumbar spine has a number of advantages. The data show that a percentage of the patients undergoing the transpsoas approach will have temporary sensory and motor symptoms related to this approach. The majority of the symptoms are thought to be related to psoas muscle inflammation and/or stretch injury to the genitofemoral nerve due to the surgical corridor traversed during the operation. No major injuries to the lumbar plexus were encountered. It is important to educate patients prior to surgery of the possibility of these largely transient symptoms.

Poster 202 Myositis Ossificans Presenting as Anterior Thigh Pain in a High School Student: A Case Report

Poster 202 Myositis Ossificans Presenting as Anterior Thigh Pain in a High School Student: A Case Report

Lateral Lumbar Interbody Fusion

A retrospective review of patients' radiographs and charts. The various methods of lumbar interbody fusion have been described in the literature. With the development of the lateral lumbar interbody fusion (LLIF) approach, a wider cage can be inserted in the intervertebral space without disrupting the anterior-posterior annulus or longitudinal ligament, with minimal danger to the retroperitoneal structures and the great vessels. There is a paucity of the literature on the radiographic and clinical outcome of this approach. The purpose of this study is to assess the radiographic change in the coronal and sagittal plane alignment of the lumbar spine after the LLIF approach using XLIF cages (Nuvasive, Inc, San Diego, CA). Radiographic and clinical outcomes, and complications associated with the approach are also described. A retrospective review of 43 consecutive patients' preoperative, immediate postoperative, and 1-year follow-up radiographs was done. All patients had LLIF procedure performed for lumbar degenerative disc disease, spondylolisthesis, or de novo scoliosis. The radiographic measurements were taken to assess change in the sagittal and coronal plane alignment of the individual instrumented disc level, overall lumbar spine, and lumbar scoliotic curves. The radiographs were also analyzed for fusion at 1 year, end-plate fracture, and other complications. The patients' hospital and clinic charts were reviewed to identify the complications and patient outcomes. There was a mean correction of 3.7 degrees (P≤0.001) at each instrumented disc level in coronal plane in 87 instrumented levels. Similarly, there was a mean gain of 2.8 degrees (P≤0.001) of lordosis at each level. In 25 patients with lumbar scoliosis (>10 degrees), mean scoliosis angle correction was 10.4 degrees (P=0.001, 43%). There was no significant change in the overall coronal or sagittal plane alignment of the lumbar spine. The most common postoperative complication (25%) was anterior thigh pain, which was transitory in the majority of cases. End-plate breach was common at the instrumented disc levels; however, it was nonprogressive in most of the cases, and did not affect the fusion or alignment at the instrumented levels. The outcome scores were improved significantly at the final follow-up. The LLIF approach is effective in correcting the coronal plane deformity and in gaining lordosis at individual instrumented levels. They parallelize adjacent end plates to correct the lumbar scoliotic curves. The complications are mostly approach-related and transitory. A larger cohort with long-term follow-up is required to establish the advantages and shortcomings of the procedure.

New Back Pain In A Collegiate Wrestler With Lumbar Degenerative Disk Disease

HISTORY: A 20 year old sophomore collegiate wrestler, with known lumbar degenerative disk disease (DDD) since high school, presented with worsening back pain and bilateral proximal anterior thigh pain. An MRI done 5 months prior to presentation had shown moderate degenerative changes at several lumbar levels, with disk height and disk desiccation. There was also an L5-S1 annulus tear with disk protrusion. He had undergone relative rest, therapeutic exercises, two lumbar trigger point injections, and two epidural steroid injections (ESI) at the L5-S1level in the interim, with the most recent ESI done three weeks prior to presentation. His back pain had initially been much better after each ESI, with symptoms acutely worsening as above. He had been able to gain some weight through exercise and denied any systemic symptoms (e.g., fever, chills), although he had symptoms of a mild upper respiratory tract infection on presentation. PHYSICAL EXAMINATION: Examination in clinic showed normal vital signs. The patient had an antalgic, guarded gait, with marked restriction of lumbar flexion to due pain. There was no tenderness to palpation. Straight leg raise bilaterally was negative, and his leg neurologic exam was normal. DIFFERENTIAL DIAGNOSIS: Acute lumbar disk herniation Acute exacerbation of lumbar DDD Lumbar strain Infectious spinal process TEST AND RESULTS: MRI lumbar spine: Diffuse annular bulging with L5-S1 central disk protrusion Normal vertebral height Markedly narrowed L3-4 disk L4 superior endplate destruction Osseous edema in L3, L4 bodies, extending in to psoas adjacent to disk Labs: Aspiration of L3, L4: Few methicilliin resistant Staphylococcus aureus (MRSA) Blood cultures (2 sites): no growth Complete blood count: normal white blood cell count, hemoglobin, hematocrit, and platelets Sedimentation rate: elevated at 45 C-reactive protein: normal FINAL WORKING DIAGNOSIS: MRSA Osteomyelitis/diskitis of L3-4, likely related to epidural steroid injection for DDD TREATMENT AND OUTCOMES: Vancomycin was administered through a central line every 12 hours for 4 weeks. After Vancomycin treatment ended, the patient took sulfamethoxazole/trimethoprim, orally, every 12 hours for 4 weeks. Three months after diagnosis, he started cardiovascular exercises and light wrestling drills.