Long-standing Low Back Pain Research Articles

Intramedullary mature teratoma in an adult: A case report

Abstract Intraspinal mature teratomas rarely occur in adults. There is little published information about the diagnosis and prognosis of adult-onset intradural spinal teratoma due to its rarity. We describe a rare case of adult intramedullary mature teratoma. A 36-year-old woman presented with complaint of a long-standing low back pain accompanied by progressive numbness of the lower extremities for a month. Magnetic resonance imaging (MRI) revealed an intramedullary tumor extending between T11 and L3. Gross excision of mass was performed with no complications. Patient symptoms improved over time and she is still under follow-up. Intramedullary mature teratoma in adults is rare but reports suggest an increase in recent years. These tumors manifest themselves based on their location within the spinal cord and the affected surrounding nerve roots. MRI is the most helpful imaging modality. But definitive diagnosis is accomplished by histopathological examination. Surgical resection is the preferred treatment. For pure mature teratomas, gross resection is comparable with radical resection. In general, prognosis for these tumors is good, with most patients showing improved neurological status or stability after resection.

Intradiscal Injection of Iron-Labeled Autologous Mesenchymal Stromal Cells in Patients With Chronic Low Back Pain: A Feasibility Study With 2 Years Follow-Up.

Degeneration of the intervertebral disc is considered to be central in pain pathogenesis in patients suffering from chronic low back pain (LBP). In recent years, the injection of mesenchymal stromal cells (MSCs) into the disc to arrest or reverse the degenerative process has been proposed as an alternative therapy. The aim of the present study was to investigate the feasibility of using iron-labeled MSCs for intradiscal injection in patients with long-standing LBP. Ten patients (7 men, 3 women, mean age 40 years, range 26-53) with chronic LBP and confirmed disc degeneration on magnetic resonance imaging (MRI) were recruited from the waiting list for planned surgery. Injection of autologous, expanded, and iron-labeled bone marrow-derived MSCs (BM-MSCs) into 1 or 2 disc levels was undertaken. Follow-up consisted of monitoring of adverse events, regular MRI examinations, and collection of patient-reported outcome measures (PROMs) for a minimum of 2 years. No complications could be detected, neither clinically nor on MRI. No statistically significant improvement was seen for PROMs on a group level up to 2 years postinjection. Three of 10 patients opted to proceed with the initially planned surgery within the first year and 2 more within 3 years postinjection. Results from this pilot cohort study show that injection of autologous expanded iron-labeled BM-MSCs is a safe procedure, in accordance with the existing body of evidence. The clinical result warrants further larger studies. 4 for therapeutic studies.

High frequency spinal cord stimulation can be more effective than traditional spinal cord stimulation in treating complex regional pain syndrome

Abstract Introduction: This case report demonstrates the effectiveness of high frequency 10 kHz spinal cord stimulation (HF10 therapy SCS) in the treatment of Complex Regional Pain Syndrome (CRPS) when compared with other treatment modalities including traditional SCS. Traditional SCS is believed to exert its action through stimulating the dorsal columns mitigating the hyperexcitable afferent signals from the periphery. Hf10 SCS delivers more stimulation to the dorsal horns targeting specifically the wide dynamic range neurons (pain projecting neurons). This creates a greater potential to suppress the sympathetic overactivity seen in CRPS while additionally removing the paresthesia's generated with dorsal column stimulation, which many find unpleasant. Patient concerns: 59-year-old Caucasian male presented with classic right lower limb symptoms of CRPS and longstanding low back pain with right-sided radiculopathy. Diagnosis: The patient developed CRPS after right leg open thrombectomy. Interventions: The patient received para-sagittal steroid epidural injections and lumbar sympathetic blocks with inadequate pain relief. He failed to improve using traditional SCS and was referred for evaluation using high frequency 10 kHz spinal cord stimulator, which the SENZA-RCT showed superior pain relief when compared to traditional stimulation. Outcome: This case is unique because the patient had no improvement with traditional SCS and reported 100% relief of CRPS pain and associated symptoms and 40% reduction in back pain while using HF10. This also is significant because back pain tends to be refractory when treated with traditional SCS. Conclusion: High frequency 10 kHz spinal cord stimulator might be an effective means of managing the symptoms of CRPS and reducing axial back pain.

Properties of Thermal Analgesia in a Human Chronic Low Back Pain Model.

PurposeFor years, heat has been used for comfort and analgesia is recommended as a first-line therapy in many clinical guidelines. Yet, there are questions that remain about the actual effectiveness of heat for a condition as common as chronic low back pain, and factors such as time of onset, optimal temperature, and duration of effect.Materials and MethodsA randomized double-blinded controlled trial was designed to compare the analgesic response to heat delivered via pulses at 45°C (experimental group, N=49) to steady heat at 37°C (control group, N=51) in subjects with longstanding low back pain. Treatment lasted 30 minutes with follow-up out to four hours. The hypothesis was that the experimental group would experience a higher degree of analgesia compared to the control group. Time of onset and duration of effect were also measured.ResultsBoth groups were similar in average duration of pain (10.3 years). The primary outcome measure was pain reduction at 30 minutes after the end of treatment, using a 10-points numeric pain scale. Reduction in pain was greater for the experimental group than the control group (difference in mean reduction = 0.72, 95% CI 0.15–1.29, p = 0.014). Statistically significant differences in pain levels were observed from the first measure at 5 minutes of treatment through 120 minutes after completion of treatment. Reduction in pain associated movement was greater in the active heat group than the placebo group (p = 0.04).ConclusionHigh-level pulsed heat (45°C) produced significantly more analgesia as compared to steady heat at 37°C at the primary end point and for an additional 2 hours after treatment. The onset of analgesia was rapid, <5 minutes of treatment. The results of this trial provide insight into the mechanisms and properties of thermal analgesia that are not well understood in a chronic low back pain model.

Fragility fractures of the sacrum: how to identify and when to treat surgically?

The increasing prevalence of fragility fractures of the sacrum (FFS) occurring predominantly in osteoporotic individuals poses a diagnostic and therapeutic challenge. The clinical presentation varies from longstanding low back pain without the patient remembering a traumatic event to immobilized patients after suffering a low-energy trauma. FFS are often combined with a fracture of the anterior pelvic ring; hence they are classified as a part of fragility fractures of the pelvis (FFP). If not displaced, the patients are treated with weight bearing as tolerated and analgesics; however, we advocate to treat displaced fractures surgically according to the fracture personality and the patient’s comorbidities. Surgical options include minimal invasive sacro-iliac screws, trans-sacral bar osteosynthesis, open reduction and internal fixation, or spinopelvic stabilization. In the light of the high complication rate associated with immobilized patients, an operative approach often is indicated to accelerate the patient’s mobility.

Ten year course of low back pain in an adult population-based cohort – The Doetinchem Cohort Study

Background The long-term course of long-standing low back pain is largely unknown since long-term data are scarce. Objective We examined the course of self-reported low back pain in the prospective population-based Doetinchem cohort over a period of 10 years. Methods Between 1993 and 2007, around 5700 randomly selected men and women in four age groups of originally 20–29, 30–39, 40–49, 50–59 years were measured three times. Logistic regression analysis was used to study the association of sociodemographic (gender, age, education, work status) and lifestyle characteristics (BMI, smoking, physical activity) with persistent and new episodes of long-standing low back pain. Results The prevalence of long-standing low back pain is quite stable over a 10 year period, approximately 20% on population level. On individual level, around 30% of the population was completely free of low back pain during the entire period, 6% can be characterized as persistent back pain sufferers. Individuals with persistent and a varying pattern have a more unhealthy lifestyle (BMI and smoking) than those without low back pain. Age, smoking, obesity and not having a paid job are associated with 10-year persistent back pain in the general population, whereas age and not having a paid job are associated in those with long-lasting back pain at baseline. New episodes of long-standing back pain are relatively frequent among women and smokers. Conclusions Low back pain in the population is characterized as very dynamic which challenges epidemiological studies highly. Long-term information on the course of back pain is needed to define severe subgroups.

What is the prognosis of back pain?

Understanding prognosis is important in managing low back pain. In this article, we discuss the available evidence on low back pain prognosis and describe how prognostic evidence can be used to inform clinical decision making. We describe three main types of related prognosis questions: 'What is the most likely course?' (Course studies); 'What factors are associated with, or determine, outcome?' (Prognostic factor or explanatory studies); and 'Can we identify risk groups who are likely to have different outcomes?' (Risk group or outcome prediction studies). Most low back pain episodes are mild and rarely disabling, with only a small proportion of individuals seeking care. Among those presenting for care, there is variability in outcome according to patient characteristics. Most new episodes recover within a few weeks. However, recurrences are common and individuals with chronic, long-standing low back pain tend to show a more persistent course. Studies of mixed primary care populations indicate 60-80% of health-care consulters will continue to have pain after a year. Important low back pain prognostic factors are related to the back pain episode, the individual and psychological characteristics, as well as the work and social environment. Although numerous studies have developed prediction models in the field, most models/tools explain less than 50% of outcome variability and few have been tested in independent samples. We discuss limitations and future directions for research in the area of low back pain prognosis.

Instrumented Slip Reduction and Fusion for Painful Unstable Isthmic Spondylolisthesis in Adults

Although in situ posterolateral fusion is considered the gold standard for surgical treatment of low-grade adult spondylolisthesis, correction of the sagittal translation by instrumented slip reduction is more controversial in adults; nevertheless it may delay adjacent level disc degeneration. The present study was undertaken to evaluate the safety and clinical outcome of operative instrumented slip reduction in 12 adults with isthmic spondylolisthesis accompanied by advanced disc degeneration at that level. This study was a retrospective review of 12 consecutive lumbar or lumbosacral isthmic slip, which underwent operative slip reduction in our institute. All adult patients having operative instrumented slip reduction of isthmic spondylolisthesis from January 2000 to December 2005 were assessed. Outcome measures included the Oswestry Disability Index (ODI) for low back pain and the visual analog scale (VAS) of back and leg pain. Patient outcome was assessed by work status, participation in sports activities and intake of pain medications. Between January 2000 and December 2005, we performed slip reduction on 12 adults aged 28 to 62 years (average 47) with symptomatic lumbar or lumbosacral isthmic spondylolisthesis. The indications for surgery were long-standing low back and leg pain that had not responded to nonoperative management. The vertebral slip ranged between 15% and 90% (average 34%). Radiologic evidence of adult slip progression was available in 5 patients, one had a de novo slip formation and the others had increased sagittal translation on flexion-extension lateral x-rays. All 12 patients underwent posterior decompression, pedicle screw fixation, slip reduction, and posterior lumbar interbody fusion. The slip was anatomically reduced by 100% in 5 patients and between 90% and 95% in 7 (average 95% for the group). X-rays revealed no evidence of instrumentation failure at a mean follow-up of 38 months (range: 18 to 72). Minimal loss of correction (5%) was observed in 2 cases. No neurologic complications were encountered. The mean preoperative ODI of 49 dropped to 12 postoperatively (range: 0 to 20). The mean preoperative VAS for back pain of 7.3 dropped to 1.6 after surgery (range: 0 to 3). The mean preoperative VAS for leg pain of 8 dropped to 1 after surgery (range: 0 to 4). Five patients were followed for more than 3 years: none had evidence of adjacent level disc disease. Our results may support performing slip reduction in selected adults with isthmic spondylolisthesis.

A 50-Year-Old Man With Chronic Low Back Pain

Mr S, a 50-year-old man, has long-standing low back pain. His pain began more than 20 years earlier with a lumbar disk herniation and has persisted despite diskectomy. He has undergone numerous treatments, but he remains disabled with ongoing pain. His treatment course is used to frame the epidemiology and pathophysiology underlying acute and chronic lumbosacral and radicular pain. The roles of neuropathic pain medications, chronic opioid therapy, physical therapy, spinal manipulation, and multidisciplinary pain treatment programs are reviewed. The indications for and outcomes associated with interventional pain treatments, including epidural steroid injection, facet blocks and radiofrequency treatment for facet-related pain, intradiskal electrothermal therapy, spinal cord stimulation, and intrathecal drug delivery, are discussed. Clinicians are given an evidence-based approach to using available treatment options for low back pain.

Predicting long-term response to strong opioids in patients with low back pain: findings from a randomized, controlled trial of transdermal fentanyl and morphine

BackgroundSome patients with long-standing low back pain will benefit from treatment with strong opioids. However, it would be helpful to predict which patients will have a good response. A fixed-term opioid trial has been recommended, but there is little evidence to suggest how long this trial should be. We assessed data from a large-scale randomized comparison of transdermal fentanyl (TDF) and sustained-release oral morphine (slow-release morphine; SRM) to determine characteristics of treatment responders.MethodsThis was a secondary analysis of a previously published 13-month randomized trial involving 680 patients with long-standing low back pain (median age 52 years, 61% women, median duration of back pain 87 months). Pain relief was recorded using visual analogue scales (VAS). Treatment response was defined as pain relief of at least 30% from baseline to any point during the trial. We used a step-wise logistic regression to identify variables that might predict response to treatment. Covariates included treatment group, sex, age, duration of pain, presence of neuropathic pain, baseline pain scores, educational/employment status, use of high doses of opioids, and social functioning (SF)-36 scores.ResultsOver half the patients in both groups (n = 370; 54% TDF, 55% SRM) were treatment responders. There were no differences between the TDF and SRM responders in terms of age, sex, type or duration of pain between responders and non-responders. The difference in response to treatment between responders and non-responders could be detected at 3 weeks. Lack of response after 1 month had a stronger negative predictive value (i.e., ability to detect non-responders) than the presence of response after 1 month. The most influential factors for predicting a response were employment status (χ2 = 11.06, p = 0.0259) and use of high doses of opioids (χ2 = 3.04, p = 0.0811).ConclusionNo clear pattern of baseline pain (type or severity) or patient characteristics emerged that could be used to predict responders before the start of opioid treatment. However, a 1-month trial period appears sufficient to determine response and tolerability in most cases.

The association between physical workload and low back pain clouded by the "healthy worker" effect: population-based cross-sectional and 5-year prospective questionnaire study.

A population-based cross-sectional and 5-year prospective questionnaire study. To investigate self-reported physical workload as a risk factor for low back pain. Both physical and psychosocial workplace factors are considered risk factors for low back pain. However, today no consensus has been reached regarding the exact role of these factors in the genesis of low back pain. Questionnaire data were collected at baseline for 1397 (and after 5 years for 1163) men and women aged 31--50 years at baseline. Low back pain ("any low back pain within the past year," "low back pain < or = 30 days in total during the past year," "low back pain > 30 days in total during the past year") was analyzed in relation to physical workload (sedentary, light physical, and heavy physical work) using logistic regression and controlling for age, gender, and social group. The proportions of workers changing between the workload groups over the 5-year period were analyzed in relation to low back pain status. At baseline no statistically significant differences in low back pain outcomes were found for workers exposed to sedentary, light physical, or heavy physical work. This was true for all age, gender, and social groups. At follow-up there was a statistically significant dose-response association between any low back pain and longstanding low back pain within the past year and increasing physical workload at baseline also after controlling for age, gender, and social group. Subjects with heavy physical workload at baseline changed statistically significantly more often to sedentary work if they experienced low back pain for more than 30 days out of the past year. Having a sedentary job might have a protective or neutral effect in relation to low back pain, whereas having a heavy physical job constitutes a significant risk factor. Because of migration between exposure groups (the "healthy-worker" effect), longitudinal studies are necessary for investigating the associations between physical workload and low back pain.

The diagnostic value of bone scintigraphy in patients with low back pain

Bone scintigraphy has been studied in two groups of patients presenting with low back pain. In one group of 38 patients suffering "nonspecific" back pain, bone scintigraphy and laboratory findings were negative in 24. There were abnormal laboratory findings in all of the remaining 14 and 7 had positive bone scans indicative of clinically significant disease. Selection of patients for bone scintigraphy in this group should therefore be influenced by abnormal laboratory findings and elevation of the erythrocyte sedimentation rate in particular. By comparison, the bone scans were reviewed from another group of patients suffering previously known malignancy. Out of 138 patients, nearly 40% showed a positive bone scan due to subsequently proven metastasis. Bone scintigraphy was positive in a further 14% as a result of osteoporotic rib fracture and vertebral body collapse. In half of these, it was not possible to exclude malignancy by scintigraphy. The present findings indicate that bone scintigraphy is not a useful procedure in patients with long-standing low back pain who have normal radiographs and normal laboratory findings.