Chronic Backache Research Articles

English

Epidural steroid injections have a long history of efficacy and safety in treating low back pain and radiculitis still their use remains controversial. OBJECTIVES: To compare and correlate clinical outcome with flouroscopic findings of interlaminar midline with caudal approaches for epidural steroid injections in low backache patients. METHODS: In a randomised manner, 40 patients with chronic low backache with or without leg radiation, either received midline interlaminar (Group A; n=20) or caudal epidural block (Group B; n=20) under fluoroscopic guidance and epidurography was noted. A two weekly follow up till 3 month done, recording VAS (Visual Analogue Scale) and Modified NASS patient satisfaction index score (NASSPSI). RESULTS: Demographic and preinjection clinical data was comparable between groups (p>0.05). Improvement in VAS score was seen in both groups compared to baseline (p 0.05). Dorsal spread was seen in all patients, ventral spread was seen in 30% patients in group A and 20% patients in group B. Nerve root spread was seen in 70% patients in Group A and 60% patients in Group B. All findings were statistically comparable between groups. Clinical outcome in terms of percentage improvement in VAS at 3 months did not correlate with ventral spread (p 0.05). More than 70% patients in both groups were satisfied (NASSPSI 1 & 2) with their results on last follow up. CONCLUSION: Presence of ventral spread of contrast did not correlate well with VAS improvement. Both approaches were comparable for improving pain and providing patient satisfaction.

Is Renal Osteodystrophy a Neglected Entity?

Sir, Renal Osteodystrophy (ROD) is the term given to the bone changes which accompany chronic renal failure [1]. We here by present a case of a middle aged female who was suffering from renal disease from more than eight years and was being treated for Ankylosing Spondylitis as co morbidity. Thirty two- year-old, female presented to our orthopedic outpatient department with chronic backache and stiffness of back and hip joints from eight years. She had many prescriptions of various physicians to show she is chronically ill. HLA-B27 report was negative. Her family history was not significant and menstrual history was normal. There was no history of trauma, fever, night sweats, night pains, loss of appetite, loss of weight, morning stiffness, involvement of smaller joints of hand and feet, bowel disturbances, recurrent UTI’s, jaundice, breathlessness, cough with haemoptysis. On examination, all movements of her back were restricted, especially flexion. Both hips had fixed flexion deformity of 15 degrees and all movements were restricted. She was unable to sit cross legged and squat. Her cardiovascular, respiratory and abdominal examinations were normal. Subsequently she was admitted for evaluation. Patient was investigated for–hemoglobin, total and differential leukocyte counts, ESR, random blood sugar, S.G.P.T., RA- Factor, C-reactive protein, serum uric acid, blood urea, serum creatinine, serum calcium, serum phosphorus, serum alkaline phosphatase, urine calcium and phosphorus estimation. She was found to have deranged renal function, as blood urea and serum creatinine were raised to 168 mg% and 4.0mg% .Her serum alkaline phosphatase was raised to 311 I.U. /LIT. Her serum calcium was low 7.0 mg% and phosphate normal 6.0 mg%. Her X-ray dorsolumbar spine AP/Lateral views revealed generalized increase in density (osteosclerosis) with calcification of anterior longitudinal ligament [Table/Fig-1]. X-ray Pelvis showed triradiate pelvis with protrusio acetabuli [Table/Fig-2]. Clinicoradiological diagnosis of Renal Osteodystrophy was made. Patient was then made to undergo ultrasound of KUB region which revealed conjoined kidneys. [Table/Fig-1]: X-ray Dorsolumbar spine AP and lateral views showing generalized increase in density with calcification of anterior longitudinal ligament [Table/Fig-2]: X-ray pelvis AP view showing triradiate pelvis with bilateral protrusio acetabuli Moriniere P, et al., in their study on disappearance of aluminic bone disease in a long term asymptomatic dialysis population have stated that Osteomalacia is a common component of bone disease in patients with end stage renal disease, although its prevalence is decreasing [2]. The disorder is characterized by low rates of bone turnover, a mineralization defect, and an accumulation of unmineralized osteoid (bone matrix). The type of Osteomalacia differs from that caused by Vitamin D deficiency, and the role of 1, 25-dihydroxy-cholecalciferol deficiency in Osteomalacia associated with end stage renal disease is unclear [3]. X-ray pelvis AP view in our patient revealed triradiate pelvis with bilateral protrusio acetabuli changes which are commonly seen in Osteomalacia. According to the study of Lewis C, et al., Osteoslerosis is seen in 20% of patients because the bony trabeculae look prominent in relation to decreased mineralization [4]. X-ray spine AP and lateral views of our patient revealed dense vertebrae. ROD is classified as osteitis fibrosa, osteomalacia, or mixed, mild, or a dynamic disease; according to the histological features. The frequency at the start of therapy for end stage renal disease has been reported by Hutchison AJ, et al., [5]. On review we have placed our case in variety of mixed disease according to this classification as features of Osteitis fibrosa were coexisting with Osteomalacia. In our opinion whenever there is a Chronic Renal Disease and the patient has positive radiological findings – should be referred to Orthopedician as they are more aware about ROD. In this case prescriptions revealed that HLA-B27 has also been done assuming Ankylosing Spondylitis.

Sinonasal Tumour causing Osteomalacia. A case report

Background: Tumour Induced Osteomalacia is a rare paraneoplastic syndrome and often unrecognized cause of hypophosphatemia with excessive production of fibroblast growth factor 23 (FGF23) leading to chronic hyperphosphaturia . It may be associated with normal or low level of 1,25-dihydroxyvitamin-D. Case Presentation: A 48 yrs old female presented with chronic low back ache, muscle pain and weakness, bony pain as well as bilateral leg pain. On examination she was found to be suffering from TIO with a sinonasal mass in CT scan. Tumour responsible for this was removed which immediately resulted in normalization of blood parameters and other complaints. Conclusion: This case is to highlight the importance of keeping this disease in mind while assessing a case of hypophosphatamia to avoid the morbidity or even death.

Comparative study of muscle strengthening exercises for treatment of chronic low backache

Background: Low back pain is a major cause of musculoskeletal disability worldwide. Objectives: To study the outcomes of different muscle strengthening exercises in treatment of low back pain Materials and Methods: One hundred and twenty patients in the age group of 20-40 years with mechanical low back pain were randomly divided intotwo groups and instructed to perform two different types of exercises for three months (Mckenzie exercise andSwiss ball exercise). Patients were assessed by Visual Analogue Scale (VAS), Modified Schober Test (MST) for extension and Oswestry Disability Index (ODI), based on pain intensity levels, range of motion, functional disability before starting the exercise programmes and after 3 months of intervention. Results were analysed using Students T Test. Results: There was no significant difference in the pre-treatment session between the two groups. VAS and ODI Values were significantly lower in post-treatment sessions as compared to pre-treatment values in both Groups but MST Values in post-treatment sessions in Group practicing Mckenzie exercise showed significant decreases. Significant decrease in VAS, MST and ODI Valueswere found in subjects practising McKenzie exercise when comparison was done between the two groups after 3 months of treatment. Conclusion: McKenzie exercise and Swissball exercise in patients with mechanical Low back pain reduce pain intensity, increaserange of movementand decrease functional disability. McKenzie exercise seems to have higher efficacy as compared to Swissball exercise.

PSY13 - Efficacy and Tolerability of CT-Guided Epidural Steroid Injections and Pharmacotherapy for Managing Chronic Low Back Ache with Radiculopathy

PSY13 - Efficacy and Tolerability of CT-Guided Epidural Steroid Injections and Pharmacotherapy for Managing Chronic Low Back Ache with Radiculopathy

Chronic low back pain and treatment with microwave diathermy

Clinical trial of 100 patients of chronic low back ache was conducted in the Department of Physical Medicine and Rehabilitation (PMR) at Sher-i-Kashmir Institute of Medical Sciences Soura a Tertiary care hospital for period of two year from January 2010 to January 2012 to find out effect of Microwave diathermy (MWD). All patients were treated with Microwave diathermy along with conventional treatment. The results were compared and student's 't' test was applied to see the level of significance. A significant improvement after treatment (P=0.000) was found. The present study suggests that short wave diathermy is effective for the treatment of patients with chronic low back pain.

Prevalence of musculoskeletal disorders among brick kiln workers in rural Southern India

Background:A variety of musculoskeletal disorders and discomfort are seen among brick kiln workers, where heavy physical work is associated with awkward working postures and manual handling of materials, leading to significant morbidity.Materials and Methods:This cross-sectional study was conducted in unorganized brick kiln industries in villages of Vellore district of Tamil Nadu and included 310 brick kiln workers. Modified Nordic Questionnaire was used to survey the prevalence of musculoskeletal disorders and the intensity of pain was assessed by the body pain discomfort scale.Results:The mean age of the workers was 37 ± 13.2 years with a range of 18-85 years. 62% (n = 192) had normal body mass index, whereas 27% (n = 85) were undernourished. The commonest posture adopted at work was squatting (67%) followed by standing (14%). Majority of workers (87%, n = 269) reported to having symptoms of pain currently of which 51% (n = 158) had pain during work. Chronic low back ache (LBA) (1 year prevalence -59%) and acute LBA (1 week prevalence-33%) were the commonest followed by chronic knee pain. More than 10 years of work was significantly associated (P < 0.05) with acute LBA and acute and chronic knee pain. Severity of the pain was also significantly (t statistic 2.476, P < 0.05) associated with job dissatisfaction.Conclusion:Long-term brick kiln workers, who adopt a specific posture for prolonged periods, have severe musculoskeletal pain that interferes with activities of daily living and reduces job satisfaction. Health education on frequent postural change, implementation and monitoring of laws among unorganized industries are recommended to bring down morbidity due to musculoskeletal disorders (MSD).

Mismatched Perfusion Defects Secondary to Recent Methyl Methacrylate Embolization

Methyl methacrylate (MMA) pulmonary embolism is a serious potential complication of percutaneous vertebroplasty. We present a case of a 28-year-old man who presented to an outside institution with pleuritic chest pain after MMA vertebroplasty of the T11 thoracic vertebra for chronic back ache secondary to a previous traumatic fracture. Multifocal MMA pulmonary embolism was identified on CT. The patient was referred to our institution following a wedge resection for pulmonary infarction. V/Q scintigraphy was performed and demonstrated normal ventilation with multiple mismatched perfusion defects bilaterally. Patient subsequently underwent central and bilateral segmental pulmonary embolectomies.

Systemic Mastocytosis: Predominantly Involving the Bone, A Case Report

Systemic mastocytosis (SM) is a rare clonal disorder of mast cells that can range from chronic smouldering type to aggressive mast cell leukaemia. It presents with non-specific symptoms like urticaria pigmentosa, unexplained flushing, hypotension and abdominal cramps, which may lead to a misdiagnosis, if there is no high index of clinical suspicion. This is a case report of a 52-year-old lady, with systemic mastocytosis, who presented with severe chronic back ache and no other clinical features. X - ray revealed lytic lesions in the lumbar vertebrae and bone marrow aspiration and a trephine biopsy examination showed infiltration by mast cells, with a positivity for Toluidine blue stain and CD 117. She was also noted to have peripheral eosinophilia, which is frequently encountered with this condition. She was diagnosed to have chronic indolent systemic mastocytosis which involved the bone predominantly.

A rare case of chronic idiopathic spinal epidural haematoma

Spinal epidural haematoma (SEH) though rare is the most frequent cause of spinal haemorrhage. It is an important cause of compressive myelopathy, frequently presents as an emergency and requires prompt diagnosis and management. SEH can be classified as secondary (e.g., secondary to coagulopathies or anticoagulant therapy), spontaneous (absence of any definite cause but associated with risk factors like minor trauma) and idiopathic (no attributable risk factors identified) or acute and chronic.1 The spontaneous and idiopathic groups comprise about 50% of cases.2 The chronic form is the rarest and its most frequent location is the lumbar spine. Magnetic resonance imaging (MRI) is the imaging modality of choice for diagnosis. Irrespective of the aetiology, the mainstay of treatment is urgent surgical decompression and evacuation of the haematoma. There are only a few reports of successful conservative treatment in this condition where symptoms and signs have resolved without surgery.3,4 Here we present an unusual case of chronic idiopathic spinal epidural haematoma where the patient was only symptomatic with chronic low backache. This article aims to discuss the pathogenesis, clinical and radiological features, and differential diagnosis in this condition.

An unusual cause of chronic backache

A 46-year-old man of mixed race had been followed up for the past 7 years at our Rheumatology clinic. He was labelled as ‘burnt out’ rheumatoid arthritis with secondary osteoarthritis. Methotrexate had been stopped 5 years ago. His main complaint was chronic lower backache that had been worsening over the past few years. He did not have any symptoms suggestive of an inflammatory arthropathy. His grandfather had similar symptoms. His siblings were all healthy. Examination revealed a middle-aged male of short stature (1.51 m). Back examination revealed loss of lumbar lordosis, limited extension with fairly preserved forward and lateral flexion. There was no evidence of peripheral arthritis and systemic examination was unremarkable. Radiographs of his lumbar spine revealed scoliosis, degenerative changes (marginal osteophytes, loss of joint space) and striking calcification of the intervertebral discs (Figure 1). Early degenerative changes of both radio carpal joints and metatarsophalangeal joints …

Health effects and acceptance of a physical activity program for older long-term unemployed workers

Long-term unemployment has negative effects on both mental and physical health. In combination with an inactive lifestyle, it often leads to functional or constitutional limitations that make reemployment in the labor market difficult especially for older adults. The presented pilot study examined a 3-month-long interventional program for improving health of older, long-term unemployed persons with regard to its effectiveness and acceptance by the target group. The low-threshold intervention was offered by a job training center that supports reemployment and was divided into lectures for enhancing the individual health competence and a supervised physical training part in a fitness center. One hundred and nineteen long-term unemployed workers (53.7 ± 3 years) took part in a prospective investigation with 3 data collection points: before intervention (T1), after intervention (T2, n = 94), and 6 month after intervention (T3, n = 59). The spectrum of methods included the assessment of nutritional status, cardiovascular risk factors, physical fitness, chronic backache, and depression. As a result of the intervention, the physical fitness improved significantly (maximal oxygen uptake: p < 0.002). Cardiovascular risk factors like systolic and diastolic blood pressure (p < 0.016; p < 0.001) and percentage body fat (p < 0.017) decreased significantly. There were also remarkable effects in the reduction in depression (p < 0.028). Chronic backache was lowered in more than 50% of the cases. The health promotion program reached people who have a desire to improve both physical and mental health. To assume responsibility for their own health may be a first step in regaining self-confidence and lowering the work placement barriers.

Can Vitamin B-Complex Aggravate the Carbamazepine Induced Toxic Epidermal Necrolysis?

Toxic Epidermal Necrolysis (TEN), which is also known as Lyell's syndrome, is a widespread, life-threatening, mucocutaneous disease that is particularly observed secondary to drugtaking and less commonly secondary to infections and immunization. Carbamazepine is associated with benign pruritic rash in 10-15% of the patients, but the life threatening dermatological syndromes like exfoliative dermatitis, erythema multiforme, the Stevens-Johnson Syndrome (SJS) and TEN are rarely seen with the carbamazepine treatment. The 32 year old female suffering from chronic backache, who was prescribed carbamazepine along with an intravenous combination of vitamin B-complex and calcium, developed fever, cough and mucocutaneous manifestations of TEN after 15 days of the treatment. She was treated in the hospital with systemic steroids, intravenous immunoglobulins, antibiotics, intravenous fluids and supportive care. In spite of the above treatment, the patient could not survive for more than seven days.

Dorsal Herniation of Cauda Equina Due to Sequestrated Intradural Disc

Intradural lumbar disc herniation (ILDH) is uncommon pathology. In present report, authors present a case of ILDH associated with dorsal herniation of the cauda equina rootlets in a 30-year-old male laborer who had chronic backache since last two years. To the best of our knowledge we are reporting this for first time. Report demonstrates the natural course of ILDH.

Multiple lumbar transverse process stress fractures as a cause of chronic low back ache in a young fast bowler - a case report

A rare case of multilevel transverse process stress fractures as a cause of low back ache in a professional cricket player has been presented. The report discusses the possible mechanism of such an injury in a cricket player and also highlights the preventive and therapeutic aspects of management in such patients. The report also stresses upon the need for early identification of such sports related injuries to prevent long term morbidity in the athletes.

Hearing loss after noise exposure

The higher field strength magnetic resonance imaging (MRI) such as 3 Tesla (T) and above generates noise that has potential detrimental effects on the hearing. Temporary threshold shifts following MRI examination have been reported for MRI with lower field strength. Such effect, however, have not been reported so far for a 3T MRI. We report a case that exemplifies the possible detrimental effects of a 3 T MRI generated noise on the auditory system. Our patient underwent investigation of his chronic backache in a 3 T MRI unit and developed hearing loss and tinnitus post-MRI examination. Hearing assessment was done using pure tone audiogram, distortion product otoacoustic emission (DPOAE) and brainstem electrical response audiometry (BERA) which revealed a unilateral sensorineural hearing loss which recovered within 3 days. However the tinnitus persisted. This is possibly a case of temporary threshold shift following noise exposure. However a sudden sensorineural hearing loss remains the other possibility.

Presence of Comorbid Somatic Disorders Among Patients Referred to Mental Health Care in the Netherlands

Referral to mental health care was examined among persons with mental disorders with and without comorbid somatic conditions to determine whether certain conditions may make detection of mental disorders by primary care physicians more or less likely. Receipt of mental health care in the primary and specialty care settings by respondents to the Netherlands Mental Health Survey and Incidence Study who had mood disorders (N=573), anxiety disorders (N=912), and substance use disorders (N=533) was examined, first broadly by any of 31 somatic conditions and then by each of the five most common conditions. Broadly, those with anxiety disorders and a somatic condition were more likely to use care in both settings (adjusted relative risk ratios [RRRs]=1.75 and 1.58 for primary and specialty care, respectively), and those with substance use disorders and a somatic condition were more likely to use specialty care (RRR=2.15). More narrowly, use of specialty care by persons with mood disorders was three times as likely for those with rheumatoid arthritis or a digestive tract disorder (RRRs=3.04 and 2.92). For anxiety disorders, specialty care was more likely for those with chronic backache (RRR=2.14) or a digestive tract disorder (RRR=3.56). For substance use disorders, those with chronic backache were six times as likely to use specialty care (RRR=6.05) and those with a digestive tract disorder were three times as likely (RRR=3.09). Poor somatic health in general seemed to increase the likelihood of use of mental health care for persons with anxiety or substance use disorders, but not for those with mood disorders. Having certain somatic conditions appeared to enhance recognition and treatment of three common mental disorders.

Ureteral Endometriosis with Obstructive Uropathy

Endometriosis is a common disease, but ureteral involvement is rare. The symptoms and signs of ureteral endometriosis mimic those of ureteral malignancy. This case report describes a woman who presented with chronic back pain for 5 years. Imaging studies showed a right small contracted kidney with hydronephrosis and a bladder tumor. Endometriosis of the right lower ureter was ultimately diagnosed. The patient was healthy without recurrence during follow-up. It is difficult to differentiate between ureteral endometriosis and malignancy; in fact, renal loss may occur before diagnosis. Ureteral endometriosis should be considered for women with ureteral obstruction manifesting as chronic backache.

Topiramate for anger control: A systematic review.

Background:Uncontrolled anger while being most commonly associated with personality disorders could also be part of many other conditions such as chronic low back ache and post-traumatic stress disorder. The intensity of anger as an emotional state at a particular time is known as “State Anger,” whereas how often angry feelings are experienced over time is known as “Trait Anger.” Anger could also manifest as expression of anger toward other persons or objects in the environment (Anger-Out), holding in or suppressing angry feelings (Anger-In) and controlling angry feelings by preventing the expression of anger toward other persons or objects in the environment or controlling suppressed angry feelings by calming down or cooling off (Anger Control).Objective:To prove the effectiveness of topiramate in the control of anger as compared to placebo and to disprove that its use leads to psychiatric adverse events by systematically reviewing the available randomized controlled trials.Materials and Methods:The basic search was performed in MEDLINE (1966 through November 2008) combined with the optimal search strategy for randomized controlled trials described in the Cochrane Reviewers’ Handbook. To update this search, we regularly screened citations from PubMed till November 2008 for eligible studies or reviews that might include eligible studies. The Cochrane Central Register of Controlled Trials (CENTRAL) was searched using the terms “topiramate” and “anger or aggression.” In addition, we screened bibliographies of reviews and identified articles. Randomized clinical trials wherein study participants were aggressive adults were included.Results:We could arrive at a weighted mean difference of −3.16 (−3.64 to −2.68) in State Anger. The reduction in the score was highest in borderline personality disorder (BPD) patients as compared to those with low back ache. Trait Anger dropped by −2.93 (−3.49 to −2.37), especially in female BPD patients. Anger In reduced more or less uniformly across the studies by −1.43 (−1.84 to −1.03). Anger Out decreased by −2.8 (−3.19 to −2.42). This effect was minimal among the male BPD patients. Anger Control uniformly increased across the four studies by 2.32 (2.00−2.64). There is sufficient evidence to suggest that topiramate is significantly effective in stabilizing the “trait anger” while reducing the “state anger.” “Anger Out” and “hostility” were significantly reduced. “Anger In” was the feature that was the least affected, although this was significant. This suggests that topiramate is effective in controlling anger. There was no suggestion of topiramate precipitating psychomorbidity.Conclusions:Topiramate appears to be a safe and effective drug in the management of anger/aggression. Additional research is needed to determine whether these results can be reproduced and how long lasting are the benefits of long-term treatment with topiramate.

A Rare Case of Medication Induced Acute Intestinal Obstruction

Purpose: 46 year old lady presented with right lower quadrant abdominal pain, nausea, vomiting and constipation for a week. Her past medical history was significant for chronic back ache, controlled on Naproxen 200 mg twice a day and methadone 10 mg three times a day. There was no history of previous abdominal surgery, inflammatory bowel disease or visceral cancers. On examination, she was tachycardic, normotensive, and afebrile. Examination of the abdomen showed no surgical scars, hypoactive bowel sounds, tender right lower quadrant with no peritoneal signs. Plain abdominal X ray showed multiple air fluid levels. CT abdomen showed dilated small bowel loops with transition point in distal ileum with mesenteric edema and stranding. The patient was kept on bowel rest with IV fluids and nasogastric decompression. Repeat abdominal films showed persistence of small bowel dilation. She underwent explorative laparotomy. Segmental small intestinal resection with end to end anastomosis and appendectomy was done. The operative findings were significant for a distinctly demarcated segment of decompressed ileum, one foot proximal to the ileocecal valve, with no obvious serosal abnormalities. On histopathology, localized mucosal ulceration with marked acute & chronic inflammation was found. There was focal submucosal fibrosis with no granulomas or thickening of muscularis propria. The appendix was normal.Final diagnosis of diaphragm disease secondary to chronic NASID use was made.She recovered well during the postoperative phase. Chronic NSAID use can cause diaphragm like strictures within the bowel leading to intestinal obstruction. This entity is called diaphragm disease. Other common etiologies should be ruled out prior to making this diagnosis. NSAID related injury should be considered in patient with intestinal obstruction of unclear etiology. Preoperative diagnosis is extremely difficult. High index of suspicion in appropriate clinical scenario is required.