Lumbar Syndrome Research Articles

LUMBAR: Association between Cutaneous Infantile Hemangiomas of the Lower Body and Regional Congenital Anomalies

To define the clinical spectrum of regional congenital anomalies associated with large cutaneous hemangiomas of the lower half of the body, clarify risk for underlying anomalies on the basis of hemangioma location, and provide imaging guidelines for evaluation. We conducted a multi-institutional, retrospective case analysis of 24 new patients and review of 29 published cases. Hemangiomas in our series tended to be "segmental" and often "minimal growth" in morphology. Such lesions were often extensive, covering the entire leg. Extensive limb hemangiomas also showed potential for extracutaneous anomalies, including underlying arterial anomalies, limb underdevelopment, and ulceration. The cutaneous hemangioma and underlying anomalies demonstrated regional correlation. Myelopathies were the most common category of associated anomalies. We propose the acronym "LUMBAR" to describe the association of Lower body hemangioma and other cutaneous defects, Urogenital anomalies, Ulceration, Myelopathy, Bony deformities, Anorectal malformations, Arterial anomalies, and Renal anomalies. There are many similarities between LUMBAR and PHACE syndrome, which might be considered regional variations of the same. Although guidelines for imaging are suggested, prospective studies will lead to precise imaging recommendations and help determine true incidence, risk and long-term outcomes.

Muscle hypertrophy of the lower leg caused by L5 radiculopathy

We report on a case with hypertrophy of the tibial muscles and to a lesser extent of the calf muscles preceded by a lumbar syndrome and sciatica. Lumbar myelography disclosed a discogenic compression of the L5 nerve root. Muscle biopsy of the peroneal muscles showed a marked type I fibre predominance and hypertrophy but no inflammatory infiltration. We consider the possibility that radiculopathy not only of the S1 nerve root but also of the L5 root can trigger hypertrophy of the musculature and must be taken into account of the differential diagnosis of unilateral focal hypertrophy of the lower leg.

The quality of life of lumbar radiculopathy patients under conservative treatment

The quality of life of lumbar radiculopathy patients conditioned by their health status is a result of both their subjective perception of the disease and their objective health status. The aim of this study was to evaluate the quality of life of lumbar radiculopathy patients under conservative treatment by means of generic and another lumbar syndrome specific questionnaires. A total of 50 patients (33 males, 17 females average age 46.1 years,) under conservative treatment in a hospital over four weeks were included in the study. They were interviewed using two questionnaires: the SF36 (Short form (36) Health Survey) generic questionnaire measuring eight domains of their quality of life summarized into two main ones (i.e. overall physical and overall mental health), and the lumbar syndrome specific North American Spine Society--Low Back Pain Outcome Instrument (NASS LBP), a questionnaire measuring four domains (functional limitations, motor and sensitive neurological symptoms, expectations from the treatment and satisfaction with it). The values of physical health domain was low as 31.1 at the beginning of the treatment, were rising over the following six months and dropped insignificantly after four years (42.1/48.7 /47.0) The mental health values (47.2) did not alter as compared to that of the general population. A values of the quality of life stabilized within six months. The neurological symptoms domain did not correlate with other value scales and domains. The quality of life of lumbar radiculopathy patients was impaired only from its physical aspect, but after conservative treatment it improved over the following six months. After four years there is an insignificant drop of all quality of life values, indicating a need for a longer term monitoring of their patients.

Image-Guided Injection Therapy in the Lumbar Spine

Degenerative changes in the lumbar spine can cause back pain with or without radiation into the lower limb. The most common sufferers are middle-aged persons between the ages of 30 and 50, but the number of patients under age 30 is steadily rising. The affected persons typically have pain that can be treated initially with physical therapy and medications. When these measures no longer suffice, injection therapy can provide additional help. Published guidelines now recommend periradicular injection therapy for radicular lumbar syndromes. This low-risk, minimally invasive form of treatment should always be preferred over a surgical procedure unless major weakness is present (7, 14–16). Computerized tomography (CT) or conventional X-ray fluoroscopy is often used to provide imaging guidance for the placement of the injecting needle into the lumbar spine. Both of these techniques result in the delivery of a certain amount of ionizing radiation to the patient. The lumbar spine and the abdominal and pelvic organs lie unprotected in the path of the X-ray beam generated by the CT scanner or fluoroscope. Health care is an important area where measures should be taken to protect against radiation injury, because, on average, about 50% of an individual’s annual dose of ionizing radiation is derived from medical procedures (1, 2). The potentially problematic use of ionizing radiation in medicine is currently under discussion in a number of countries, not only in Germany (3, 11, 12), particularly in light of the increasing use of computerized tomography (17). The purpose of this article is to raise awareness of the problem of ionizing radiation in image-guided injection therapy.

Influence of the weather on the course of lumbar syndromes

Sensation of pain during lumbar syndromes is correlated with weather situations, the definition of which takes into consideration traditional as well as new methods of weather classification. To this end, it was necessary to develop an algesia index for the purpose of defining the subjective pain sensation by classifying it in different groups enabling the application of medico-meteorological statistics. The medical data were correlated with the following meteorological arametes: Weather-phase scheme according to Brezowsky-Ungeheuer; temperature-humidity environment; weather situations for Central Europe; synoptic index cycle; advention of temperature in medium altitudes of the atmosphere; vorticity for cyclogenesis. The following results were obtained: Pain sensation in the lumbar area shows a significant dependence on weather situations. Althoguh singular meteorological parameters are not important, the human body is affected primarily by the sum total of all weather elements.

The effect of lumbar relief orthoses with abdominal compression on esophago-gastrointestinal motility

To investigate the effect of lumbar ortheses with abdominal compression on gastro-oesophageal reflux and gastrointestinal transit. In a prospective study 20 consecutive patients with lumbar syndrome treated with lumbar orthesis (10 female, 10 male, median age 54.6 years) were investigated for gastro-oesophageal reflux, mouth-to-cecum transit time (MCT), and whole-gut transit time. Gastro-oesophageal reflux was assessed performing an ambulatory pH metering of the distal oesophagus over a period of 10 h with and without ortheses on two separate study days. After positioning of the pH catheter patients ingested a liquid-solid test meal labelled with 10 g lactulose and 750 g indigocarmine to determine MCT with the hydrogen breath test and whole-gut transit by the first appearance of indigocarmine in the stool. Dyspepsia was assessed by using a standardized questionnaire. Lumbar ortheses induced a significant increase in reflux time (pH < 4) (8.1 vs 4.1%), total number of reflux episodes (102.5 vs 69.5) and duration of longest reflux episode (6.0 vs 3.7 min) (P < 0.05). 12 patients with ortheses revealed an increase in relative reflux time (2.1-24.5%, median: 8.2%) more than two standard deviations compared to previously obtained normal values. In these patients during ortheses dyspeptic symptoms correlated significantly with reflux time (r = 0.6; P < 0.05). In contrast, MCT and whole-gut transit time in patients with and without ortheses did not differ significantly (85 vs 85 min; 10.2 vs 9.6 h). Lumbar ortheses with abdominal compression, nowadays frequently used in the lumbar syndrome, produce gastro-oesophageal reflux associated with dyspepsia. Gastrointestinal transit time is not affected, though.

Neue Aspekte in der Diagnostik der Spondylodiscitis

New aspects regarding the diagnosis of spondylodiscitis are shown by means of the casuistics of a severe immobilizing lumbar syndrome. In this special case only the MR-examination was able to make clear the diagnosis, at a time when all other diagnostic methods failed. The MR-examination was taken as primary and progressive diagnostic method and it also decided about therapeutic consequences.

Centralization: Prevalence and Effect on Treatment Outcomes Using a Standardized Operational Definition and Measurement Method

Retrospective, observational cohort design. Purpose 1 was to determine the association between age, symptom chronicity, and prevalence of centralization in a sample of patients with nonserious cervical or lumbar spinal syndromes referred to a hospital-based outpatient rehabilitation clinic. Purpose 2 was to examine if classifying these patients at intake to centralization or noncentralization predicts functional status, pain intensity, and number of treatment visits at discharge from rehabilitation. Purpose 3 was to compare clinically meaningful changes in functional status and pain intensity between patients subgrouped by centralization and noncentralization. Variations in operational definitions and measurements used to identify centralization affect patient classification, contribute to variation in reported prevalence rates, and influence treatment strategy and outcome interpretation. Investigating a standardized operational definition and measurement method for centralization may reduce practice and outcomes variation. Adults (n=418) with cervical or low back syndromes (mean +/- SD age, 58 +/- 17 years; range, 19-91 years; 33% male; 76% lumbar symptoms; 53% chronic symptoms) were assessed. Therapists classified patients using a standardized operational definition and method for centralization during initial evaluation. Prevalence rates were calculated for centralization by age and acuity. Multivariate models were used to assess discharge functional status, pain intensity, and visits while controlling important variables. Percentage of patients subgrouped by centralization and noncentralization achieving minimal clinically important differences (MCID) in functional status and pain intensity was assessed. Overall prevalence rate for centralization was 17%, but increased for patients who were younger and reported acute symptoms regardless of body part. For patients with lumbar syndromes, noncentralization was associated with lower discharge functional status and more pain, but not associated with number of visits compared to patients classified as centralization. For patients with cervical syndromes, noncentralization was associated with more pain but not associated with functional status or number of visits compared to patients classified as centralization. Pain pattern classification affected percentage of patients with lumbar and cervical impairment achieving MCID. Results supported the clinical use of a standardized definition of centralization to facilitate patient classification and management and interpretation of outcomes.

Effects of the Treatment of Acute Lumbar Painful Syndrome (ALPS) by "Praxis Method" during the Period from 1996 to 2000

Acute lumbar syndrome occurs suddenly and is accompanied with strong pain in the lower part of the back. The most frequent APLS causes are vertebral (herniation of intervertebral disc, subluxation of intervertebral disc, subluxation of intervertebral joint, fracture of vertebra--traumatic or pathological), or extravertebral (subluxation of sacroiliac joint, acute bursitis of iliolumbar segment, muscle injuries or injuries of tendo-ligamentous apparatus of lumbosacral region). The treatment of acute lumbar painful syndrome is classified as medical, alternatively medical, surgical and combined. On the basis of durable experience, "Praxis method" as a treatment of lumbar pain (general and acute) is being applied in the Centre for Physical Medicine and Rehabilitation "Praxis" in Sarajevo. During the period from 1996 to 2000, the total number of 5.663 patients were examined in the centre "Praxis". Out of that number, 17.7% (1.003) of patients had acute lumbar painful syndrome (ALPS). Immediately after the therapeutic manipulation, which included "Praxis method, 31.5% (317) patients experienced the cessation of pains followed by ending of the treatment. The length of treatment for the rest of patients lasted: 1-7 days in 412 or 41.07 % of patients, 8-21 days in 195 or 19.48% of patients, and more than 21 days in 79 or 7.88% of patients. For all patients (1.003) the average treatment duration was 6.6 days. The recidivation occurred in 127 patients (12.66%). Throughout the treatment successfulness estimation according to clinical results scaled from 0 to 5, it was confirmed that out of the total number of 831 patients (82.85%) results were excellent in 459 patients (45.76%) or very good in 372 patients (35.09%). The average age of patients was ranging between 35 and 45 years (621 patients or 61.9%). The male/female distribution was 2:1.

Balneotherapy in the treatment of subjective symptoms of lumbar syndrome

Chronic low back pain is a degenerative rheumatic disease and is characterized by various symptoms and clinical signs. Balneotherapy represents a therapy by various hot or warm baths in natural mineral waters of specific physical and chemical characteristics. When used externally, they have mechanical, chemical and thermic effects. Balneotherapy of lumbar syndrome includes: individual baths, swimming in the pool, hydrokinesitherapy, underwater massage, underwater extension, mud therapy, mud baths. The therapy should be closely monitored for optimal efficacy and it is necessary to examine: functional status of the lumbosacral region, general functional status (level of activity), lower extremities, pain measurement, use of non-steroid antirheumatic and analgesic agents. In order to follow-up the effects of therapy and establish the prognosis it is important to perform: detailed anamnesis, anthropometric measurements, socio-epidemiological research, clinical examinations. Lumbar syndrome is usually caused by a degenerative disease of the spinal column. More than 25% of people under 45 years of age are unable to work due to chronic low back pain. That is why preventive measures, prompt diagnosis and adequate therapy are of utmost importance.

Medical training therapy in lumbar syndromes.

Chronic low back pain can be considered to be one of the most frequently treated and most costly diseases in modern industrial societies. Dysfunctions and imbalances of the spine-supporting muscles increase the risk of low back pain. Consequently preventive treatment and rehabilitation have to aim at preserving and restoring the full capacity of the spine-supporting muscles as well as training coordination and spine-friendly behaviour. In addition to various measures of pain therapy, physiotherapeutic treatment including neuro-physiotherapy, physical treatment (eg electrotherapy), balneotherapy and supportive behavioural training, medical rehabilitation therapy (MRT) ranks among the most effective ways of treating low back pain. MRT applies guidelines and methods of exercise methodology within medically indicated programmes of preventive treatment and rehabilitation. Various objectives of MRT are outlined with special regard to the stages of MRT treatment, emphasizing positive adaptation of the neuro-muscular system in the course of rehabilitation. Physicians are responsible for MRT diagnosis and control. Taking into account the base disorder and the progress of therapy physiotherapists and the physicians in charge determine MRT objectives and treatment strategies.

Injection therapy in lumbar syndromes

Injection therapy as part of orthopaedic pain treatment is of major importance in sciatica. It helps to differentiate unclear complaints and allows a break through of the vicious circle of pain and muscle spasm. Pharmacological principles and possible complications have to be observed. The different techniques need experience and manual training. The paper describes the various injection techniques in detail.

DOSE–RESPONSE RELATIONSHIPS BETWEEN WHOLE-BODY VIBRATION AND LUMBAR DISK DISEASE—A FIELD STUDY ON 388 DRIVERS OF DIFFERENT VEHICLES

In a longitudinal study, the dose–response relationships between long term occupational exposure to whole-body vibration and degenerative processes in the lumbar spine caused by the lumbar disks were examined. From 1990 to 1992, 388 vibration-exposed workers from different driving jobs were examined medically and by lumbar X-ray. For each individual, a history of all exposure conditions was recorded, and a cumulative vibration dose was calculated allowing comparisons between groups of low, middle, and high intensity of exposure. 310 subjects were selected for a follow-up four years later, of whom 90·6% (n=281) agreed to participate. In comparing the exposure groups, the results indicate that the limit value ofazw(8h)=0·8 m/s2should be reviewed. The best fit between the lifelong vibration dose and the occurrence of a lumbar syndrome was obtained by applying a daily reference ofazw(8h)=0·6 ms2as a limit value. The results became more distinct still when only those subjects were included in the statistical analysis who had had no lumbar symptoms up to the end of the first year of exposure. The prevalence of lumbar syndrome is 1·55 times higher in the highly exposed group when compared to the reference group with low exposure (CI95%=1·24/1·95). Calculating the cumulative incidence of new cases of lumbar syndrome in the follow-up period yields a relative risk ofRRMH=1·37 (CI95%=0·86/2·17) for the highly exposed group. It is concluded that the limit value for the calculation of an individual lifelong vibration dose should be based on a daily reference exposure ofazw(8h)=0·6 m/s2. With increasing dose it is more and more probable that cases of lumbar syndrome are caused by exposure to vibration.

Is a preoperative evaluation program in treatment of patients with chronic lumbar syndrome useful?

The Pre-Operative Evaluation Program (PEP) in the USA is a 1-week outpatient program for patients who have physical pathology which could be improved with surgical intervention. Patients are prepared for surgery and their hospital stay through an education process that includes educational groups, understanding of anatomy, pain and stress management, psychological testing and exercises to improve strength and spine techniques to improve functional abilities. The orthopedic clinic in Kassel developed a 14-days inpatient preoperative evaluation and education program (PEP) for potential surgical candidates with chronic back or neck pain.

Surgical treatment and results in patients suffering from lumbar spinal steoses

Stenosis of the lumbar spinal canal is contributing to 3-5% of all patients operated on a lumbar nerve root compression syndrome. Morphologically, a reduction of the midsagittal diameter of the spinal canal to less than 12 mm or stenoses of the lateral recessus or foramen intervertebrale have been described. In our department 37 patients with a lumbar spinal stenosis have been surgically treated between 1982 and 1987. Spinal stenosis is a disease of aged patients mostly suffering for a long history. The main symptoms are lumbar and sciatic pains, neurological deficits and a claudicatio intermittens spinalis. Neuroradiologically, the diagnosis can be confirmed by CT, myelography or MRI. These studies were demonstrating the stenosis in 69% at the level of L4/5, multiple stenoses have been found in 22% of all cases. An additional disc herniation existed in 35% of the patients. Concerning the specific complaints of the patients and their neuroradiological findings, the extent of the surgical decompression was decided on individually in each patient. We performed 22 laminectomies, 11 hemilaminectomies, in 3 cases an extended flavectomy and in one case an implantation of a dorsal column stimulation device. The postoperative follow-up period, ranging from 3 months to 3 years, demonstrated a complete recovery in 53%, a marked reduction of complaints in 44% of all cases. One patient did not respond to surgical treatment, but in the remaining cases surgical treatment led to satisfactory results.

Functional testing in lumbar nerve root compression syndromes. An evaluation in patients with normal neurological findings

A functional test using downhill walking was evaluated in relation to the myelographical examination in 33 patients with a suspected lumbar nerve root compression syndrome despite normal neurological findings. Any changes of motor or reflex signs or of straight leg raising were accepted as test results. They were noted in a decision matrix and the positive and negative predictive value (PPV and NPV, respectively) calculated. The PPV of any deterioration of the neurological status resulting from the test as a sign of abnormal myelographical findings was calculated to be approximately 85 per cent, the corresponding NPVs being approximately 50 per cent. In its present form, this functional test is inadequate as a screening procedure in these patients.

Lumbar Spinal Stenosis Syndrome

Seventy-six operations were performed by the author for lumbar spinal stenosis syndrome over 25 years. The characteristic symptoms of pain, sensory changes, and intermittent pseudoclaudication in connection with the extent of nerve root compression confirmed by laboratory examinations and the operative findings allow the author to stress the following points. (1) In Greece, lumbar spinal stenosis syndrome is not a very common entity. (2) Spinal stenosis cases of acquired type are the most common while those of developmental character are very rare, only two in this series, (3) Surgical intervention, which is the treatment of choice, includes a generous decompressive procedure that must free all the neural elements. Sometimes it is necessary to remove part or all of the facets in one or more levels. (4) The rate of complications is low, and complications are of minor character. (5) The results on the whole are very satisfactory and lasting, provided the planning and execution of the operation are based on sound preoperative assessment using both clinical examination and laboratory investigation. (6) Development of the acquired form of stenosis of the spine seems not to be preventable. The pathogenesis of the syndrome has not been fully established.

Advertising

I wish to call your attention to an instance of questionable advertising in the May 1988 issue of Physical Therapy. The ad appears on pages 720 and 721 and is entitled “Comparative Study Finds McKenzie Protocol 97% Effective Against Lumbar Syndrome.” The title of this advertisement is misleading for two reasons. Firstly, no “lumbar syndrome” exists. Lumbar syndrome is not a medical entity and is not even listed in the International Classification of Diseases, 9th revision, Clinical Revision, Volume 2. It is a pseudomedical term serving only to confuse the issue. Secondly, the title of this advertisement printed as it is in the style usually reserved for research articles encourages the reader to believe he or she is reading a scientific paper. Following the title, a summary paragraph also is printed in the style usually reserved for research articles. Gene A. Billadeau Vice President, Nelson Walby, Inc, 6950 Wayzata Blvd, Ste 433, Minneapolis, MN 55426

Disc deterioration in low-back syndromes. A prospective, multi-center CT/discography study.

Disc deterioration and pain provocation in different low-back pain syndromes was studied using computed tomography (CT) discography. Data were prospectively collected for 300 patients (816 discs). Patients were classified by their pre-discography diagnosis of disc herniation (DH), degenerated disc (DD), lumbar syndrome (LS), lumbar radicular syndrome (LRS), or other. The CT/discograms were classified by discographic pain response, the amount of degeneration and annular disruption. Eighty-two percent of DH patients, 80% of DD, 56% of LS, and 59% of LRS patients had both positive discographic pain provocation and moderate or severe disc deterioration. The study indicates that intradiscal pathology plays a major role in nonspecific low-back pain syndromes.

Comparative Study Finds McKenzie Protocol 97% Effective against Lumbar Syndrome

A program utilizing patient response to repeated lumbar movements (including flexion, extension, lateral bending and rotation), known as the McKenzie method, has now been demonstrated to be twice as effective in alleviating low back pain compared to traction and back schools. This is a capsule summary of the “Extrac '86” study as detailed in The Journal of Musculoskeletal Medicine 1987; vol. 4(9):27–34 and 4(12):63–74.