Intermittent Low Back Pain Research Articles

SymTC: A symbiotic Transformer-CNN net for instance segmentation of lumbar spine MRI

Intervertebral disc disease, a prevalent ailment, frequently leads to intermittent or persistent low back pain, and diagnosing and assessing of this disease rely on accurate measurement of vertebral bone and intervertebral disc geometries from lumbar MR images. Deep neural network (DNN) models may assist clinicians with more efficient image segmentation of individual instances (discs and vertebrae) of the lumbar spine in an automated way, which is termed as instance image segmentation. In this work, we proposed SymTC, an innovative lumbar spine MR image segmentation model that combines the strengths of Transformer and Convolutional Neural Network (CNN). Specifically, we designed a parallel dual-path architecture to merge CNN layers and Transformer layers, and we integrated a novel position embedding into the self-attention module of Transformer, enhancing the utilization of positional information for more accurate segmentation. To further improve model performance, we introduced a new data synthesis technique to create synthetic yet realistic MR image dataset, named SSMSpine, which is made publicly available. We evaluated our SymTC and the other 16 representative image segmentation models on our private in-house dataset and public SSMSpine dataset, using two metrics, Dice Similarity Coefficient and the 95th percentile Hausdorff Distance. The results indicate that SymTC surpasses the other 16 methods, achieving the highest dice score of 96.169 % for segmenting vertebral bones and intervertebral discs on the SSMSpine dataset. The SymTC code and SSMSpine dataset are publicly available at https://github.com/jiasongchen/SymTC.

Complicated uveitis in a spondyloarthritis patient: a case report

Background: Ophthalmic manifestations, like uveitis, might be one of the complications of spondyloarthritis. Many individuals experiencing acute uveitis are unaware that spondyloarthritis has already been present. The late diagnosis and treatment of uveitis can result in permanent vision impairment. This case report presents the diagnosis and management by a rheumatologist and ophthalmologist of a spondyloarthritis patient with complicated uveitis. Case: On October 27, 2021, a 42-year-old male patient came to the rheumatology outpatient clinic of Dr. Soetomo General Hospital, Surabaya, Indonesia with intermittent low back pain for the past fourteen years, which worsened in the last eight months. The pain was accompanied by morning stiffness for about an hour after getting-up every day, gradually relieved by stretching. The lumbosacral x-ray revealed bilateral sacroiliitis. The patient also came to the ophthalmology outpatient clinic with sudden left eye pain and gradually blurred vision for the past two years. He was diagnosed with spondyloarthritis with bilateral uveitis, secondary glaucoma, and secondary cataract on both eyes. He was given methotrexate, sulfasalazine, sodium diclofenac, topical timolol 0.5%, topical atropine, acetazolamide, and methylprednisolone. The low back pain and impaired vision were improved after three months of treatment. Conclusion: Uveitis should be suspected as a relatively common complication of spondyloarthritis. Early diagnosis and treatment of this uveitis might prevent permanent damage.

A Rare Cause of Rapid Death in Patients With Crohn’s Disease

Question: A 35-year-old male patient was hospitalized due to intermittent low back pain, abdominal pain, and fever. He had a 1-year history of suspected ankylosing spondylitis (AS) and had short-term NASIDs use for about 1 month. He was diagnosed as having Crohn’s disease (CD) and AS 1 month before admission. Computed tomography enterography revealed transmural ileocolitis without obvious fistula or abscess and segmental small intestinal lesions (Figure A, B, C). Meanwhile, the patient had bilateral sacroiliitis of grade 2 on computed tomography (CT) scan with no peripheral joint involvement. Anti–tumor necrosis factor therapy was recommended, however, he refused because of the cost and inconvenience. Oral methylprednisolone (0.75 mg/kg/d) and sulphasalazine were effective in improving his abdominal and joint symptoms in the first month after treatment. He continued tapering glucocorticoids until developing fever 4 days before admission.

Sacral dome resection and single-stage posterior reduction in the treatment of high-grade spondylolisthesis in a young girl

Introduction: The treatment of high-grade spondylolisthesis remains controversial in terms of in situ fusion versus reduction. The aim of operation in this patient is to restore the spino-pelvic alignment, sagittal profile of the spine and prevention of progression of slip with a minimal neurological risk.
 Case presentation: 18 years old schooling girl referred with a history of backache and right lower limb numbness over lateral aspect of foot for four years duration. She also had intermittent lower back pain, produced by long distant walking and relived by rest. It was aggravated by standing for long duration. There was no radiation of pain, no red flag sign or no cauda equina symptoms. Apart from her right lower limb neurology which was her power MRC grade IV in L5 and S1 myotome, other examinations were normal. X-Ray revealed grade V spondyloptosis. MRI showed evidence of right exiting L5 nerve root entrapment with grade V spondyloptosis. She underwent single stage posterior instrumentation of L4 - S1vertebrae, sacral dome resection, reduction of L5 over S1, interbody fusion of L5 - S1 and posterolateral intertransverse fusion of L4 to S1 vertebrae. She was ambulated on post-operative day one without brace. There was no worsening of neurology.
 Conclusion: Lumbosacral spondylolisthesis grade V can be treated using posterior approach alone to obtain reduction, decompression, and solid fusion. The sacral dome resection is a shortening osteotomy of the lumbosacral spine which allows a single-stage reduction of L5 without lengthening of lumbosacral region in high-grade spondylolisthesis, which helps to avoid neurological complications.

Pseudo-tumor renal tuberculosis: a case report

BackgroundRenal lesion is a very frequent location of tuberculosis disease, the diagnosis of which is often difficult and delayed due to its atypical clinical presentations, especially in its pseudo-tumoral form.Case presentationPatient of 54 year old was referred after a kidney mass was found on an abdominal ultrasound. In addition, the patient reported the notion of minimal intermittent low back pain with weight loss. On computed tomography, it was a nodular lesion of the superior pole of the right kidney, and it has a heterogeneous density and a suspicious appearance. A total nephrectomy was performed by subcostal incision. Pathological examination of the specimen revealed the presence of diffuse gigantocellular granulomas with caseous necrosis suggestive of renal tuberculosis.ConclusionDespite the rarity of this form, renal tuberculosis should always be thought in order to avoid radical treatment.

Spinal Ganglioneuroma

An otherwise healthy 57-year-old man presented with intermittent low back pain and was incidentally found to have a left-sided paraspinal mass invading the spinal canal and causing spinal cord compression. He underwent a T11-12 hemilaminectomy, facetectomy, and instrumented fusion for a gross total resection with a good clinical outcome. Pathology revealed the lesion to be a ganglioneuroma. Ganglioneuroma is a rare and interesting pathology. These tumors are benign peripheral neuroblastic tumors derived from the neural crest and found along the entire neuroaxis. Tumors come to clinical attention if they cause symptomatic compression of neural structures or are found incidentally on imaging. Additionally, as these tumors share a common lineage with pheochromocytomas, systemic symptoms can be observed resulting from secretion of vasoactive peptides. The pathologic diagnosis of ganglioneuroma is predominantly based on morphology.

Laparoscopic surgical approach for the treatment of piriformis syndrome: Intrapelvic decompression technique

Introduction: Piriformis syndrome is an uncommon disease resulting from the piriformis muscle’s compression of the sciatic nerve. Pain and numbness in the buttocks and down the leg are the most common symptoms. This study analyzes the laparoscopic surgical treatment of piriformis syndrome. Methods: We report three cases of piriformis syndrome diagnosed in our hospital. The first case was a 40 years old woman with a 7-year history of intermittent low back pain and sciatica on her right side. Hyperesthesia and cutaneous allodynia were observed in the right sciatic nerve dermatome. The second case was a 30 years old woman with a 2-year history of sciatica on her left side. The third case was a 30 years old woman with a 2-year history of sciatica on her right side. All the patients underwent laparoscopic decompression surgery, which was performed to release the sciatic nerve or sacral nerve roots. Results: The patients were reexamined at the postoperative 3rd and 6th months. Their visual analog scale (VAS) scores were found to be decreased from 10/10, 9/10, and 7/10 to 0/10, 1/10, and 0/10, respectively. Conclusion: Due to the very few cases in the literature, pelvic piriformis syndrome is an exclusively clinical diagnosis. If the sciatica is refractory to conservative treatments, laparoscopic exploration and decompression surgery of the pelvic nerves and piriformis muscle could be an option.

Teaching NeuroImages: A Ruptured Lumbar Disc Mimicking Spinal Tumor.

A 47-year-old healthy man presented with intermittent low back pain radiating to the left calf; within 1 month, the pain worsened at night and disturbed his sleep. Examination showed paresthesia in left lateral calf, weakness in left ankle plantarflexion, and decreased ankle reflex. Neuroimaging revealed near-total obliteration of the spinal canal by a 2 × 1.2 cm nodule at L5-S1 level with ring enhancement under gadolinium-enhanced MRI (figure 1). The patient underwent surgery for a presumed spinal tumor. The intraoperative and pathologic findings revealed ruptured intervertebral disc without neoplasm (figure 2). The clinical presentation and image characteristics of a large ruptured disc can mimic a spinal tumor.1,2

Two Cases of Ureteral Polyp With Intermittent Lower Back Pain

Two Cases of Ureteral Polyp With Intermittent Lower Back Pain

Surgical treatment of patients with degenerative grade I lumbar spondylolisthesis combined with spinal stenosis using minimally invasive bilateral decompression

Objective. To analyze clinical and radiological outcomes of minimally invasive bilateral decompression through a unilateral approach in the treatment of patients with degenerative grade I spondylolisthesis combined with lumbar spinal stenosis. Material and Methods. A total of 28 patients with degenerative grade I lumbar spondylolisthesis combined with spinal stenosis at one or several levels with clinical manifestations of neurogenic intermittent claudication and low back pain were operated on using the method of bilateral microsurgical decompression through a unilateral approach. The minimum follow-up period was 1 year. Clinical outcomes was assessed using VAS, Oswestry and MacNab questionnaires. Central stenosis of the spinal canal was graded according to Shizas classification based on MRI data, and the degree of segment stability according to Hanley and progression of spondylolisthesis in a neutral position were assessed by a functional lumbar spondylograms before surgery and in the long-term period. Results. The average hospital stay was 3.07 ± 0.26 days. The average duration of the operation was 145.07 ± 44.67 minutes. When assessing pain by VAS questionnaire, a significant decrease in the median value of the intensity of pain was noted: in the leg – from 7.0 [7.0; 8.0] to 1.0 [1.0; 2.0], in the back – from 5.0 [4.0; 5.0] to 1.0 [1.0; 2.0]. The ODI questionnaire showed a decrease in the median indicator of disability from 60.0 [56.0; 64.0] to 15.0 [12.0; 19.0]. Assessment of radiological outcomes showed a slight increase in the parameters of anteroposterior translation (on average +0.42 mm) and segmental rotation (on average +1.03 degrees) of the operated segment during functional tests, and a slight increase in spondylolisthesis (on average by 1.42 %), which in general did not affect clinical outcomes. Conclusion. Retrospective analysis of minimally invasive bilateral decompression through unilateral approach in patients with degenerative grade I lumbar spondylolisthesis combined with spinal stenosis without segmental instability provided the evidence of significant clinical efficacy of the method with a low risk of iatrogenic segment instability in the late postoperative period.

A case of epidural venous plexus enlargement presenting with radiculopathy and low back pain mimicking lumbar disc herniation

Epidural venous plexus enlargement, presenting with low back pain and radiculopathy, is a rare cause of nerve roots impingement. Lumbar epidural varices can mimic as a lumbar disc herniation clinically and radiologically. For this reason, the diagnosis is commonly missed or delayed leading to persistent symptoms. We present a young female patient with intermittent low back pain and radiculopathy, unresponsive to medical treatment. Keywords: Epidural venous plexus enlargement, lumbar disc herniation, radiculopathy, low back pain

Clinical case of pubic symphysis diastasis in a pregnant woman with atypical clinical features

This article presents a clinical case of pubic symphysis diastasis in a pregnant woman with atypical clinical features. From 24 weeks of gestation, the patient noticed an intermittent low back aching pain radiated to posterior surface of the right thigh. The pain was regarded as a manifestation of lumbar osteochondrosis, and the patient did not receive specific treatment. At 39-40 weeks of pregnancy, the woman complained of severe pain in the left iliac region that appeared while lying on the left side or turning in bed. The differential diagnosis included acute abdomen and pubic symphysis diastasis. During diagnostic research, clinical features of acute abdomen were not found. The diagnostic tests such as tenderness palpation of pubic symphysis, P4 test, Patricks test, modified Trendelenburgs test, and Mennells test were positive. According to ultrasound, the width of the pubic symphysis was 8.9 mm, with a 2 mm deviation of pubic ramus relative to the sagittal plane, ill-defined margin and inhomogeneous structure of the symphysis due to hypoechogenic inclusions with a total area of about 50%. Thus, the patient was diagnosed with pubic symphysis diastasis of the 2nd degree. Given the severe pain syndrome and a high risk of pubic symphysis fracture during labor, this case required surgical delivery. The postoperative period elapsed without complication.

Physical and psychological workload in men with and without low back pain

Current and retrospective physical and psychological workload was studied in 148 mean, 45-55 years old. The men represented three groups with respect to low back health status: Healthy low back (Group 1, n = 36), intermittent low back pain (LBP) (Group 2, n = 91) and chronic LBP (Group 3, n = 21). The methods used were a self administered questionnaire, a rating scale of perceived exertion, and blind expert assessment built on a classification of job titles. Group 1, the back-healthy subjects, had been less exposed to heavy physical work than subjects with intermittent LBP (Group 2) and chronic LBP subjects (Group 3) through their whole working-career and in their present work (p < or = 0.05, p < or = 0.01). Group 2 tended to be significantly less exposed in their present work than Group 3 (p < or = 0.06). Non-neutral working postures were reported more often in Groups 2 and 3 than in Group 1 (p < or = 0.05, p < or = 0.001). Both groups 2 and 3 perceived present and earlier work to be more strenuous than Group 1, with respect to the low back (p < or = 0.000). Subjects in the healthy low-back group had lower values in the qualitative demand index (too difficult working tasks" and "too great responsibility") than subjects in Groups 2 and 3 (p < or = 0.01). This study indicates that more attention should be given to the individual's perception of physical workload."

My new normal: A patient's perspective on polymyalgia rheumatica

My new normal: A patient's perspective on polymyalgia rheumatica

Escherichia coli Spondylodiscitis: A Case Report and Literature Review

Introduction: Spondylodiscitis is an infectious inflammatory disease with the involvement of an intervertebral disk and adjacent vertebral bodies. Hematogenic spreading of microorganisms from an infectious site is the most common pathophysiologic cause of vertebral osteomyelitis. In this report, a case of Escherichia coli spondylodiscitis was described and a review of literature was also performed on cases with E. coli spondylodiscitis. Case Presentation: A 68-year-old woman referred to our hospital with a 2-month history of intermittent fever, weight loss, and low back pain. On physical examination, we found obvious bulging with the dimensions of 4 × 20 cm on about L1 - L4 vertebral area. Lumbosacral MRI revealed the evidence of L2 - L3 spondylodiscitis. She had positive blood and urine cultures with ciprofloxacin-sensitive E. coli and successfully treated without surgery after 8 weeks. Nine articles (including 9 patients) regarding E. coli spondylodiscitis or vertebral osteomyelitis have been published from the 1st of January 1985 to the 10th of August 2019. In addition to these cases, here we report 10th case of E. coli vertebral osteomyelitis. Four patients were female and 6 were male. The mean age was 52 years with a range of 12 - 69. Seven cases had a history of fever, and overall, fever and pain at the site of vertebral involvement were the most common symptoms. Conclusions: In our reported patient, returning to the patient’s medical history and finding a previous urinary tract infection and E. coli bacteremia was crucial in helping to diagnose and treat the patient. In our review, 7 patients had positive blood cultures, a finding that emphasizes the diagnostic value of this test. Escherichia coli spondylodiscitis is a relatively rare disease that has usually a source of urinary tract infection and its clinical signs and symptoms are not distinguishable from vertebral osteomyelitis due to other agents and finally, blood culture can be helpful as a diagnostic method.

Research on multimorbidity in primary care. Selected abstracts from the EGPRN meeting in Tampere, Finland, 9–12 May 2019

Multimorbidity challenges existing healthcare organization and research, which remains disease and single-condition focused. Basic science approaches to multimorbidity have the potential to identify important shared mechanisms by which diseases we currently think of as distinct might arise, but there is a pressing need for more applied and health services research to understand better and manage multimorbidity now. There are several recent clinical guidelines, which make recommendations for managing multimorbidity or related issues for patients such as polypharmacy and frailty. However, the evidence base underpinning these recommendations is often weak, and these guidelines, therefore, also help define a research agenda. A key problem for researchers and health services is that multimorbidity is very heterogeneous, in that ‘intermittent low back pain plus mild eczema’ presents very different challenges to researchers and health services compared to ‘active psychosis plus severe heart failure’. Identifying important but tractable research questions is therefore not always straightforward. This presentation will identify important gaps in the evidence, and illustrate how they might be filled. The focus will be on two areas where there is consensus that better evidence is needed to inform care design and delivery: (1) organizational interventions to implement more coordinated and holistic care; and (2) interventions to improve medicines management in people with multimorbidity and polypharmacy. These illustrate both the potential for imaginative research, but also the scale.

Spine injections in athletes

A major proportion of athletes have intermittent acute low back pain at some stage of their sport life. Some athletes develop chronic low back pain, which may be a major source of failing in sports. Facet, epidural and intradiscal steroid injections for specific pain generators in the spine show different short- and long-term results. They can improve low back pain for specific pain generators experienced by back pain patients and might be able to help some of these athletes to avoid open surgery and shorten the time until return to sports (RTS). Facet and intradiscal steroid injections provide only short-term effects in axial low back pain and should therefore be considered with caution, whereas the different forms of epidural steroid injections for sciatica caused by radicular compression seem to be a well-proven adjuvant treatment option within a conservative therapeutic regimen. An overview of the literature related to the use of different steroids has shown that non-particulate steroids provide better results regarding safety and avoidance of major complications, especially when used at the cervical spine. However, in Germany the use of these steroids is still off-label and patients have to provide their informed consent prior to injection. In summary, careful use of spinal injections within a conservative physiotherapeutic regimen seems to improve chronic back pain and, in turn, reduce the time of RTS.

Low Back Pain - Recreational Soccer Player

HISTORY: A 21-year-old female recreational soccer player presented with intermittent right-sided low back pain for two years. She denied any trauma or inciting event. Pain was localized to the right lumbosacral region without radiating leg pain and was described as dull and aching. It was rated on average 5/10 on a numerical rating scale and associated with nausea when pain worsened. Symptoms were worse with prolonged sitting, and several times in the last month she reported worsening of typical pain with alcohol intake. She denied leg weakness, numbness, or bowel/bladder dysfunction. She participated in six weeks of physical therapy, which helped with nausea and pain with sitting, but she continued to have pain with alcohol consumption. PHYSICAL EXAM: Full and symmetric strength, sensation, and reflexes. Mild lumbar dextroscoliosis. No palpable step-offs. Tenderness over right lumbar paraspinals and above right iliac crest. No tenderness over PSIS. Full, non-painful range of motion with lumbar flexion and extension. No pain with facet loading. Full, non-painful hip range of motion. Negative FABER, FADIR, and straight leg raise test bilaterally. DIFFERENTIAL DIAGNOSIS: 1. Discogenic pain 2. Facet-mediated pain 3. Disc herniation 4. Muscular strain 5. Sacroiliac joint dysfunction 6. Intrabdominal/ intrapelvic etiology 7. Neoplasm TESTS AND RESULTS: 1. Lumbar spine X-rays: -Normal alignment, normal vertebral body and disc space height -Partial lumbarization of S1 vertebral body -Five degrees of lumbar dextroscoliosis 2. MRI lumbar spine: -Lumbarization of S1 vertebral body -Normal disc heights and signal -Normal central canal and neural foramen size throughout lumbar spine -T1/T2 hyperintensity within S2 vertebral body, likely lipoma -Increased T2 signal medial to right kidney suggestive of hydronephrosis 3. Renal ultrasound: -Moderate right hydronephrosis with extrarenal pelvis. No nephrolithiasis. 4. Renogram with furosemide: - Right kidney with blunted flow and delayed clearance improved slightly with furosemide, consistent with partial obstruction at right ureteropelvic junction FINAL/WORKING DIAGNOSIS: Ureteropelvic junction obstruction causing Dietl’s crisis TREATMENT AND OUTCOMES: 1. Referral to urology 2. Resolution of pain and improvement in renal function after pyeloplasty

Low Back Pain - Recreational Soccer Player

HISTORY: A 21-year-old female recreational soccer player presented with intermittent right-sided low back pain for two years. She denied any trauma or inciting event. Pain was localized to the right lumbosacral region without radiating leg pain and was described as dull and aching. It was rated on average 5/10 on a numerical rating scale and associated with nausea when pain worsened. Symptoms were worse with prolonged sitting, and several times in the last month she reported worsening of typical pain with alcohol intake. She denied leg weakness, numbness, or bowel/bladder dysfunction. She participated in six weeks of physical therapy, which helped with nausea and pain with sitting, but she continued to have pain with alcohol consumption. PHYSICAL EXAM: Full and symmetric strength, sensation, and reflexes. Mild lumbar dextroscoliosis. No palpable step-offs. Tenderness over right lumbar paraspinals and above right iliac crest. No tenderness over PSIS. Full, non-painful range of motion with lumbar flexion and extension. No pain with facet loading. Full, non-painful hip range of motion. Negative FABER, FADIR, and straight leg raise test bilaterally. DIFFERENTIAL DIAGNOSIS: 1. Discogenic pain 2. Facet-mediated pain 3. Disc herniation 4. Muscular strain 5. Sacroiliac joint dysfunction 6. Intrabdominal/ intrapelvic etiology 7. Neoplasm TESTS AND RESULTS: 1. Lumbar spine X-rays: -Normal alignment, normal vertebral body and disc space height -Partial lumbarization of S1 vertebral body -Five degrees of lumbar dextroscoliosis 2. MRI lumbar spine: -Lumbarization of S1 vertebral body -Normal disc heights and signal -Normal central canal and neural foramen size throughout lumbar spine -T1/T2 hyperintensity within S2 vertebral body, likely lipoma -Increased T2 signal medial to right kidney suggestive of hydronephrosis 3. Renal ultrasound:-Moderate right hydronephrosis with extrarenal pelvis. No nephrolithiasis. 4. Renogram with furosemide: - Right kidney with blunted flow and delayed clearance improved slightly with furosemide, consistent with partial obstruction at right ureteropelvic junction FINAL/WORKING DIAGNOSIS: Ureteropelvic junction obstruction causing Dietl’s crisis TREATMENT AND OUTCOMES: 1. Referral to urology 2. Resolution of pain and improvement in renal function after pyeloplasty

Improvement in Radicular Symptoms but Continued Facet Arthropathy and Axial Back Pain Following Rupture of a Facet Joint Synovial Cyst

Lumbar synovial cysts are benign fluid collections thought to form in a background of facet joint degeneration, allowing for fluid to leak from the joint capsule and form cysts in the synovium. Although often asymptomatic, patients with symptomatic synovial cysts will present with low back pain and possibly an associated radiculopathy. Clinicians can consider conservative management, epidural steroid injection, surgical intervention, or facet joint block with aspiration and rupture. This case describes a 59-year-old male facilities manager with intermittent low back pain for one year with worsening right-sided radicular symptoms secondary to a lumbar facet joint synovial cyst in the context of severe facet arthropathy and microinstability. The patient’s low back pain and radicular symptoms were refractory to conservative treatment. Imaging demonstrated a lumbar synovial cyst and subsequent management included transforaminal epidural steroid injection and facet joint block with cyst aspiration and rupture. The patient’s radicular pain resolved but axial lumbar pain returned after 3 weeks of relief. Follow-up imaging demonstrated decreased cyst size with fluid accumulation and joint space widening. Although the cyst was successfully decompressed with resolution of radicular pain, the underlying facet arthropathy remains contributing to persistent axial low back pain and potential for continued degenerative changes including cyst recurrence.