Back Trauma Research Articles

Fibrodysplasia Ossificans Progressiva: Early Diagnosis Is Critical yet Challenging

A 5-year-old boy presented with a large firm left infrascapular mass after a fall from a chair 3 weeks earlier. Ultrasound scanning findings were consistent with intramuscular trauma. Seven days later, with another ultrasound scan, a postero-lateral thoracic mass extending to the posterior neck was shown. Infection or malignancy was suspected, and biopsy of the lesion was considered. However, a radiologist recognized that the history of remote minor back trauma was discordant with persistent swelling and tenderness and reviewed all imaging.

Propriospinal Myoclonus in a Child

A 6-year-old girl was experiencing repetitive involuntary and massive jerks immediately involving limbs and trunk. The first motor events appeared approximately at 1 year old and only 5 months after a back trauma. Myoclonus became progressively more frequent and more violent, causing episodes of falls. Neurological examination showed jerks characterized by upper limb abduction, lower limb abduction, and head-body hyperextension. Apart from these motor events, the neurological examination was normal. The results of vitamin B(12) and folate, antinuclear antibody, anti-DNA, anti-Tiroglobulin, anti-thyroid peroxidase antibody, lupus anticoagulant, anti-cardiolipin antibody, rheumatoid factor, and C3 and C4 were unexceptional. Electroencephalography and brain and spinal magnetic resonance imaging were unremarkable. Electromyographic records with surface electrodes showed that duration of myoclonic jerks was ranging from 100 to 300 ms. We thought she had propriospinal myoclonus because of presence of the spreading through the shoulder, upper limbs, and lower limbs in addition to thoracolumbar paraspinal muscles.

An unusual cause of spinal cord compression

A 26-year-old man in good health fell with a hyperextension injury to his low thoracic spine while playing football. He experienced a sudden shock-like pain in his back that was followed by immediate paraplegia and complete loss of sensation below the umbilical region. He was taken by paramedics to the hospital where an MRI was performed (Fig. 1). There was a loss of sphincter function. He had no prior history of back trauma or pain.

Report on the Fifth African League Against Rheumatism Congress in Nairobi, Kenya

The Fifth Congress of the African League Against Rheumatism (AFLAR) was held in Nairobi, Kenya, from 18th to 22nd February 2007. Shortly after their arrival in Nairobi, delegates required little reminder of their presence in Africa. Many of the magnificent tall imposing giraffes from the Nairobi National Park were on hand to welcome delegates as they made their way from the airport to the city. The conference venue, the Hotel Intercontinental, is situated directly opposite the headquarters of the Kenyan government, the Parliament Buildings complex. The warmth and friendliness of the Kenyan people and the hospitality and efficiency of the organizing committee set the scene for a memorable congress. The organizing committee for the conference, led by Dr J. Amolo Alouch, provided a forum for scientific deliberations by delegates from all over the world and succeeded in placing the care of patients with musculoskeletal disorders on the agenda of the Health Ministry and the Government of Kenya. The distinguished local dignitaries who participated in the various congress events included the Vice President of Kenya, Honorable A. Moody Awori, and the Director of Medical Services of the Ministry of Health, Dr James W. Nyikal, and the Head of International Relations for Kenya, Dr Ahmed Ogwell. Their presence and contributions provided testimony to the gratitude and support from the Kenyan government for the staging of this event in Nairobi. They acknowledged the importance of addressing the needs of patients with rheumatic disorders while focusing on the life threatening challenges posed by communicable diseases such as HIV infection, tuberculosis and malaria. The Fifth AFLAR Congress was a historic event as there were participants from 15 countries in Africa, many of whom have only a few or no rheumatologists. The countries represented were Egypt, Ghana, Nigeria, Democratic Republic of Congo, Congo Brazzaville, Cameroon, Sudan, Uganda, Tanzania, Namibia, Botswana, Zimbabwe, South Africa, Zambia and Mauritius. The conference proceedings included presentations by delegates from all parts of Africa and nearly 20 international delegates from North America, South America, Europe and Asia. International dignitaries and contributors included Professor Abraham Kutzbach, President of International League of Associations for Rheumatology (ILAR), Professor Tore Kvien, President of the European League Against Rheumatism (EULAR) and Professor Ho-Youn Kim, President-Elect of Asia Pacific League of Associations for Rheumatology (APLAR). Professor Anthony Woolf delivered a keynote address on “The Global Burden of Musculoskeletal Conditions and the Need for Public Health Strategies” during the opening ceremony for the congress. He reported that the burden of musculoskeletal conditions has been recognized by the United Nations and World Bank by the endorsement of the Bone and Joint Decade 2000–2010. He provided statistics on the burden of the various forms of arthritis, low back pain, osteoporosis and musculoskeletal trauma. He noted that many of these conditions can be prevented or effectively treated and evidencebased strategies for their control have been developed. Clin Rheumatol (2007) 26:1033–1035 DOI 10.1007/s10067-007-0620-3

THE CLASSIC: Pyogenic Vertebral Osteomyelitis

THE CLASSIC: Pyogenic Vertebral Osteomyelitis

Surgical treatments for lumbar disc disease in adolescent patients; chemonucleolysis / microsurgical discectomy/ PLIF with cages.

The herniated lumbar disc (HLD) in adolescent patients is characterized by typical discogenic pain that originates from a soft herniated disc. It is frequently related to back trauma, and sometimes it is also combined with a degenerative process and a bony spur such as posterior Schmorl's node. Chemonucleolysis is an excellent minimally invasive treatment having these criteria: leg pain rather than back pain, severe limitation on the straight leg raising test (SLRT), and soft disc protrusion on computed tomography (CT). Microsurgical discectomy is useful in the cases of extruded or sequestered HLD and lateral recess stenosis due to bony spur because the nerve root is not decompressed with chymopapain. Spinal fusion, like as PLIF, should be considered in the cases of severe disc degeneration, instability, and stenosis due to posterior central bony spur. In our study, 185 adolescent patients, whose follow-up period was more than 1 year (the range was 1 - 4 years), underwent spinal surgery due to HLD from March, 1998 to December, 2002 at our institute. Among these cases, we performed chemonucleolysis in 65 cases, microsurgical discectomy in 94 cases, and posterior lumbar interbody fusion (PLIF) with cages in 33 cases including 7 reoperation cases. The clinical success rate was 91% for chemonucleolysis, 95% for microsurgical disectomy, and 89% for PLIF with cages, and there were no nonunion cases for the PLIF patients with cages. In adolescent HLD, chemonucleolysis was the 1st choice of treatment because the soft adolescent HLD was effectively treated with chemonucleolysis, especially when the patient satisfied the chemonucleolysis indications.

Cartable et pathologie rachidienne: Légende ou réalité ?

Back pain has become a real public health concern both for adults and children. In general, patients complain of moderate pain. While the topic was long ignored by the scientific community, the number of publications has increased over the last three years. We reviewed the literature to separate real evidence from speculations. Recognized risk factors for spinal pain are: female gender, poor general status, family history of back pain, particular psychological patterns, time spent sitting watching television, history of spinal trauma, intense physical activity, practicing competition sports, and age (more frequent in adolescents than children). Several recent papers have drawn attention to the role of the weight of the school backpack in children, particularly when its weight exceeds 20% of the child's body weight. Many children carry heavy backpacks which for some may weigh 30% to 40% of their body weight. Several groups have estimated that the maximum should be 10% of the body weight. It appears that time spent carrying the backpack as well as its weight is an important factor favoring back pain. Backpacks can injury the head or face, as well as the hands, the elbow, the wrist, the shoulder, the foot and the ankle. Back trauma is observed as the sixth most common injury. The ‘weak point’ is the shoulder and not the back. A poorly positioned backpack can modify posture and gait. Carrying the backpack with two shoulder straps affects posture and gait less than carrying it on one shoulder. The posture of the spine changes when the weight of the backpack increases. This is probably one of the reasons why many parents who consult believe that there is a relationship between the weight of the backpack and scoliosis or kyphosis, observed in many of their children. It is proven that adolescents who suffer from back pain will probably have chronic back pain as adults, but there is not evidence to our knowledge demonstrating a relationship between the development of spinal deviation and the weight of the backpack. Recent studies have been conducted to design backpacks allowing a better weight distribution and comfort. This type of backpack appears to have a limited benefit. Furthermore, the question of mode must not be ignored for children and adolescents. Backpacks with one sack in front and one in back certainly provide better weight distribution but are they acceptable for children and adolescents?

Disabling Spondyloarthrosis Risk Factors in Valley of Mexico Workers

Background The objective of this study was to describe the most prevalent physically disabling conditions for insured workers belonging to the Mexican Social Security Institute (IMSS) in the Valley of Mexico and to identify risk factors for disabling spondyloarthrosis. Methods Retrospective cases and prevalent controls from IMSS clinics in the Mexico City metropolitan area were studied. Eighty cases were IMSS workers reporting disability due to spondyloarthrosis; 80 controls were active workers at the same workplace and shared the economic activity of the cases. The 1995 IMSS Disability Report was reviewed. From this report congenital conditions of the musculoskeletal system, obesity, history of trauma, and sociodemographic patient characteristics were assessed. Results The most important risk factors were a history of spina bifida (odds ratio [OR] = 29.3, 95% confidence interval [95% CI] = 5.3–161; p = 0.0009), supernumerary vertebrae (OR = 21.3, 95% CI = 5.3–95; p = 0.0001), history of low back (lumbar) trauma (OR = 3.9, 95% CI = 1.9–8.3; p = 0.0004), flatfoot (OR = 11.7, 95% CI = 1.9–69, p = 0.02), and obesity (OR = 2.0, 95% CI = 1.06–4.03; p = 0.04). Conclusions A history of congenital deformity of the musculoskeletal system, spinal column trauma, and obesity were risk factors most associated with work disability due to spondyloarthrosis.

Clinical Science (41)

Does early intervention with a light mobilization program reduce long‐term sick leave for low back pain? (Central Hospital in Hedmark, Ottestad, Norway) Spine 2000;25:1973–1976.This randomized, controlled clinical trial investigated the effect of a light mobilization program on the duration of sick leave for patients with subacute low back pain. Early intervention with information, diagnostics, and light mobilization may be a cost‐effective method for returning patients quickly to normal activity. In this experiment, patients were referred to a low back pain clinic and given a simple and systematic program as an outpatient treatment. Patients sick‐listed 8 to 12 weeks (N = 457) for low back pain were randomized into two groups: an intervention group (n = 237) and a control group (n = 220). The intervention group was examined at a spine clinic and given information and advice to stay active. The control group was not examined at the clinic, but was treated with conventional primary health care. At 12‐month follow‐up assessment, 68.4% in the intervention group had returned to full‐duty work, as compared with 56.4% in the control group. Conclude that early intervention with examination, information, and recommendations to stay active showed significant effects in reducing sick leave for patients with low back pain. Comment by Susan Anderson, MD.This is a randomized controlled clinical trial to compare patients that have been sick listed for more than 8 weeks in Norway. Comparison was between a control group that received conventional primary health care and an intervention group that was examined at a spine clinic, given information, and advised to stay active. The authors wanted to examine if an early intervention with information, diagnostics, and light mobilization may be a cost‐effective method for returning patients quickly to normal activity. This study involved 457 patients that were sick listed 8 to 12 weeks for low back pain. The inclusion criteria for the study was based on 1) 8 to 12 weeks being “sick‐listed,” 2) age (18 to 60 years), and 3) diagnosis that included back pain, low back pain, leg and thigh pain, back pain without sciatica, and sciatica. Exclusion criteria included pregnancy, recent low back trauma, cauda equina symptoms, cancer, osteoporosis, rheumatic low back disease, and ongoing low back treatment. The intervention used was modification of Indahl's light mobilization program where the patient was referred to a spine clinic, answered standard questionnaires, and was interviewed and examined by a treatment team consisting of a physician and a physiotherapist. Any somatic findings during the examination were explained to the patient and information was given about their importance. All radiographs were shown and explained. The idea was to educate the patient and dedramatize their problems. The patient was assured of a good prognosis and informed of the importance of remaining active to avoid development of muscle dysfunction. The physiotherapist individually advises the patient on how to train and stretch at home. They were also advised on how to manage the back pain and resume normal activity. The patients in the control group were not examined at the clinic, but were treated with primary health care, which included at least one visit to a general practitioner. The patients were reassessed at 3 months, 6 months, and 12 months. The assessment was to determine if the patient had returned to full duty work. At each of the assessments, the intervention group had a higher percentage of patients that had returned to full duty work. At the 12‐month follow‐up, 68.4% in the intervention group had returned to full duty work as compared with 56.4% in a controlled group.This study demonstrates that a consultation with thorough examination, information, reassurance, and encouragement shows a significant effect in reducing sick leave for patients with low back pain as compared to the conventional health care guidelines used by general practitioners that tend to recommend bed rest, caution, and reduced activities. The authors suggest that information and fear reduction when offered systematically may reduce the fear of “doing something wrong” to the back. This may then prevent unnecessary activity and long sick leave.

Hourly Trends in Occupational Low Back and Cumulative Trauma Disorders

Very few studies have investigated the variations in occupational injuries throughout the day. The main objective of this study was to examine hourly trends in reported claims of occupational injuries with special emphasis on low back disorders (LBDs) and cumulative trauma disorders (CTDs). The data were obtained from the records of a major insurance carrier. The results showed that the number of claims per hour exhibited a Gaussian-like distribution with highest reported numbers occurring between 7:00 am and 11:00 am. There was an observed increase in LBD claims during the morning hours when compared to the afternoon. In addition, there was a pronounced increase in the number of CTD claims at 9 a.m. indicating a possible carry over effect from nocturnal and early morning pain commonly experienced in CTD sufferers. More revealing, normalized claims (per number of people working at a given hour) showed a dramatic increase during the evening and early morning hours when compared to normal working hours. For both the overall and LBD claims, the rates during the night and early morning periods were up to three times higher than during the typical day-time working hours. However, this trend was not as pronounced for the CTD claims. The findings of the study indicate that special attention should be paid to activities and work processes performed during night and early morning hours of the day.

A Methodology for the Analysis and Prediction of Back Injuries in Apparel Manufacturing

This research uses a proactive methodology for the analysis and prevention of industrial back injuries, called Continuous Safety Sampling Methodology (CSSM), which was developed at the University of Texas at El Paso. The CSSM utilizes principles of work sampling and control charting. Sampling is performed to observe the occurrence of conditions which may become hazardous (prone to cause instantaneous or cumulative back trauma) in a given system. These conditions, known as dendritics, could eventually result in an injury or occupational disease. The Continuous Safety Sampling Methodology performs a random sampling for the occurrence of these dendritics. The collected data is then used to generate a control chart. Based on the pattern of the control chart, a system “under control” is not disturbed whereas a system “out of control” is investigated for potential conditions becoming hazardous. Appropriate steps can then be taken to eliminate or control these potentially dangerous and costly conditions to maintain a safe system. The CSSM was successfully implemented in an Apparel manufacturing plant, providing insights on how the system was becoming dangerous, and providing insights as to the reasons why.

Correlates of back problems and back-related disability in the United States

The purpose of this study is to identify correlates of back problems and back disability in the adult population of the United States. Cross-sectional analyses were performed using data from the 1989 National Health Interview Survey (NHIS). Weighted polytomous logistic regression modeling was performed to estimate odds ratios adjusted for the effects of covariates. The prevalence of a disabling back condition, vs. no back condition, was relatively higher among subjects aged 25–64 years, male, non-high-school graduates, unemployed, living in the West, with disabling non-back morbidities, and with body mass index and weight above the 50th percentile. Among workers, those in technical, sales, clerical, private household, service, precision production and repair, or transportation occupations were relatively more likely to report disabling back conditions, compared to workers in professional occupations. Among adults with back problems, age greater than 34 years, weight above the 50th percentile, and history of back trauma were associated with chronic back disability. Although the magnitudes of the associations are not large, they may have enormous public health implications because of the high prevalence of back problems and related disability.

Epidural Abscess Associated With Intravenous Drug Abuse in a Pregnant Patient

The association between intravenous drug abuse and epidural abscess is well known; however, this association has not previously been reported in a pregnant patient. The classic manifestation of epidural abscess is a febrile patient with back pain that progresses rapidly to radicular pain, spinal cord dysfunction, weakness, and then complete paralysis. Although this condition is rare during pregnancy, these serious complications necessitate prompt diagnosis and intervention. If spinal infection is suspected, magnetic resonance imaging should be performed immediately. After epidural abscess is diagnosed, emergent decompressive laminectomy and appropriate antibiotic coverage are necessary. Herein we describe a 27-year-old pregnant patient with epidural abscess probably related to use of contaminated needles for intravenous administration of drugs and subsequent hematologic spread of staphylococci to the epidural space. The differential diagnosis of epidural abscess can be difficult, and management options must consider the well-being of both the mother and the fetus.

Camptocormia

Camptocormia is a disabling psychiatric condition characterized by a fixed flexion of the spine usually occurring dining the stress or anticipation of battle. We present an illustrative case study and a summary of six cases. In this clinical sample the camptocormia was associated with a high likelihood of a history of significant back trauma; this lends to difficulty in assigning a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). Camptocormic patients retained in the military have a poor prognosis; rapid diagnosis and medical separation is recommended.

Disc degeneration in young gymnasts

Magnetic resonance imaging (MRI) was performed on 35 young competitive gymnasts and 10 control subjects in order to detect the number of degenerated discs and other lumbar spinal disorders. Lumbar radiographs were obtained from all gymnasts who showed evidence of disc abnormality on MRI. Eleven gymnasts had suffered from episodes of low back pain during exercises and eight were found to have evidence of back trauma. Only 3 of the 35 gymnasts had MRI evidence of degenerated discs associated with Scheuermann's manifestations and spondylolysis. Lumbar radiographs confirmed the diagnosis in these three cases. The results indicate that despite the excessive range of motion and strong axial loading of the lumbar spine that are associated with gymnastic maneuvers, incurable primary damage to the intervertebral discs is uncommon in young gymnasts during growth.

Breaker's Back

To the Editor.— I wish to bring to the attention of Pediatrics readers a cause of back trauma among urban adolescents. In the Comprehensive Child Health Program, we recently saw a male adolescent who complained of lumbar back pain, relieved by rest and aggravated by bending over and by vigorous physical activity. He had also noted a mass about the size of an orange in the center of his back; he denied any history of trauma to the area.

Safety and health in boatbuilding and repair.

Boatbuilding is a complex, chemically intensive industry which employs approximately 43,000 workers in the United States, 77% of them in shops with fewer than 20 workers. Boatbuilders and repairers are at high risk of occupational injury from falls, lacerations, low back trauma, repetitive motion, noise, burns, fires, and explosions. Also they are at risk of acute and chronic illness, including dermatitis, toxic hepatitis, peripheral neuropathy, and chronic encephalopathy as a result of their occupational exposures to such materials as styrene, resins, solvents, paints, welding fumes, and coating systems. Boatbuilders also are exposed to toxic woods and to lead. Hazard recognition is the first step toward reduction of injury and disease in boat building. Control of recognized hazards is achieved through engineering controls, ventilation in particular, and through medical surveillance. Strong programs for injury prevention and for health and safety education will produce significant health and economic benefit in the boatbuilding industry.

Back stress: the effects of training nurses to lift patients in a clinical situation

The high incidence of low back pain in nurses related to patient handling tasks, shown by Stubbs et al. (1981), confirms the view that nurses use lifting techniques which are highly stressful. The training nurses receive in lifting appears to vary throughout the United Kingdom, both in time spent and method of training (Raistrick, 1981), but two facts need to be considered if the training is to be effective. These are, that 90% of the nursing workforce is female and that tasks performed are not repetitive. For example, the types of bed or chair and space available to manoeuvre may be different within the ward situation; the patients’ individual heights and weights vary, and the patients’ levels of dependence on the nurses may change daily. It has been shown that women take a surprisingly long time to become experienced lifters. Even for women performing repetitive tasks in heavy industry it took three years for subjective feelings of pain and fatigue to be reduced (Nemecek, 1976). The usual lecture-demonstration on the principles of good lifting techniques, followed by practice on colleagues, therefore should be regarded as just the beginning of the training programme for learner nurses. The basic principles then have to be applied with patients who vary considerably (in weight, size and ability to cooperate) in clinical situations that are often far from ideal. The ‘double peak’ of incidence of nurses first experiencing low back pain demonstrated by Cust et al. (1972) (Fig. 1) suggests two major mechanisms of back injury, causing an acute episode in the learner, or after twenty years, the cumulative effect of minor back trauma seen in the experienced nurse. A similar pattern of incidence has been described by Troup (1965) in male heavy industrial workers. It is not just the major back injury that the nurse must avoid; she must also consciously reduce the back stress experienced throughout the nursing activities, especially when the task involves moving patients. The safe lifting and handling of patients demands a high level of skill, for it requires that the nurse knows and understands the causes of high levels of truncal stress, analyses the particular situation and then plans the task carefully so that the least possible stress is

Hematogenous Candida osteomyelitis: Report of three cases and review of the literature

Candida osteomyelitis of the spine and intervertebral disc developed in three patients without evidence of back trauma or overlying cutaneous infection. Two patients were prone to the development of disseminated candidlasis by the use of multiple antibiotics and other predisposing modalities following abdominal surgery. One patient had no identifiable cause for development of the infection. The diagnosis was established in all three cases by x-ray evidence of osteomyelitis and culture from needle aspirate. Two patients had bone scans consistent with infection. Each patient received different therapy. One was treated with amphotericin B, one with spinal fusion and 5-fluorocytosine, and one with no antifungal therapy. All patients had complete healing of the involved vertebrae. Candida organisms have the potential to cause destructive bone infection following hematogenous dissemination. The presence of Candida osteomyelitis may be helpful In diagnosing disseminated candidiasis.

建設労働者の腰痛症とその業務起因性 : 第1篇 自覚症状及びレントゲン所見の分析

Recently, there has been an increase in the number of workers complaining of low back pain. This is related to the changing patterns of work due to industrialization and automation which have been noted to increase the stress in workers' bodies. Inflexible regulations and attitudes on the part of governmental administration make it difficult to meet the changing needs and the working conditions of the workers. In 1968, a new regulation came into force, which states that low back pain without a history of trauma is admitted as an occupational disorder. However, such cases of low back pain as spondylosis deformans is likely to be attributed to advancing age, and spondylosis or spondylolisthesis would be considered as a congenital anomaly. Physical examinations and X-ray findings among construction workers in Okayama City revealed the following results: 1. Fortyfive percent of the workers complained of the low back pain. 2. Low back pain is related to the type of work performed. And, the worker's posture is related to the occurrence of the low back pain. 3. One third of the workers with low back pain reported a history of low back trauma. 4. Workers with low back pain showed a high incidence of other musculo-skeletal symptoms. 5. Disappearance of physical lordosis, punch tenderness over vertebrae, weakness of extension tendon of the big toe, positive Lasegue test and differences in patellar and Achilles tendon reflexes between both sides were more often observed among the workers with low back pain than among the workers without it. 6. Spondylosis, spondylolisthesis and spondylosis deformans were noted to have high incidence among the workers studied, particularly in the younger age groups. The findings described above indicate that physical and radiologic examinations verify that both trauma and chronic stress are related to the occurrence of the low back pain. We conclude that low back pain is related to the person's occupation. This raises some serious questions regarding the interpretation of the new regulation. There is a great need for additional investigations on low back syndromes.