Resolution Of Low Back Pain Research Articles

Public versus Private Care in the Military Health System: Evidence From Low Back Pain Patients.

There is a longstanding debate about whether health care is more efficiently provided by the public or private sector. The debate is particularly relevant to the Military Health System (MHS), which delivers care through a combination of publicly funded federal facilities and privately contracted providers. This study compares outcomes, treatments, and costs for MHS patients obtaining care for low back pain (LBP) from public versus private providers. A retrospective cohort study was completed using TRICARE Prime claims data from April 2015 to December 2018. The cohort was identified using International Classification of Diseases Ninth Revision and Tenth Revision diagnostic codes and then followed for 12 months after the index diagnosis to assess treatments, outcomes, and costs. Claims were classified as originating from either public or private providers. The primary outcome measure was resolution of LBP, defined as an absence of LBP diagnoses during the 6-to-12-month window following the index event. Instrumental variable models were used to assess the impact of care setting (i.e., private versus public), conditioning on the covariates. A regional measure of the fraction of private care was used as an instrument. Resolution of LBP was achieved for 79.7% of 144,866 patients in the cohort. No significant association was found between resolution of LBP and fraction of privately provided care. Higher fraction of private care was associated with a greater likelihood of opioid treatments (odds ratio, 1.22; 95% CI, 1.02-1.46) and a lower likelihood of benzodiazepine (odds ratio, 0.56; 95% CI, 0.45-0.70) and physical therapy (odds ratio 0.55; 95% CI, 0.42-0.74) treatments; manual therapy was not significantly associated with the fraction of private care. There was a significant negative association between the fraction of private care and cost (coefficient -0.27; 95% CI, -0.44, -0.10). This study found that privately provided care was associated with significantly higher opioid prescribing, less use of benzodiazepines and physical therapy, and lower costs. No systematic differences in outcomes (as measured by resolved cases) were identified. The findings suggest that publicly funded health care within the MHS context can attain quality comparable to privately provided care, although differences in treatment choices and costs point to possibilities for improved care within both systems.

Complete Resolution of Refractory Axial Low Back Pain After Myomectomy.

We present a case of a 39-yr-old woman with a 3-mo history of axial low back pain who was found to have a 3.8-cm uterine fibroid, which was initially thought to be an incidental finding. Her low back pain failed to respond to conservative management, and she was eventually referred to gynecology. Her pain subsequently resolved after myomectomy. To the best of our knowledge, complete resolution of low back pain after myomectomy has not been previously described in the literature. Although uterine fibroids are commonly noted on imaging, they are often ignored. We encourage clinicians to consider fibroids as pain generators, especially when treating patients with refractory axial low back pain.

Six cases of occult sacral meningocele.

Background: Intrasacral occult sacral meningoceles (OSM) are uncommon congenital lesions that rarely become symptomatic, even over a patient’s life time.Methods: We operated on six patients with symptomatic OSM diagnosed on MR studies (all six) and/or CT examinations (four cases).Results: All six patients had uneventful postoperative recoveries. Nevertheless, despite the resolution of low back pain and radiculopathy, preoperative bladder dysfunction improved postoperatively in only one patient.Conclusion: Few cases of patients undergoing surgery for symptomatic OSM are reported in the literature. Here, we recount our experience with six patients with symptomatic OSM who demonstrated significant postoperative neurological recoveries except for rare improvement in bladder function.

Deep Pelvic Side Wall Anatomy; A Case of Laparoscopic Management of Vaginal Vault Fistula to the Presacral Area

<h3>Study Objective</h3> Video presentation showing retroperitoneal dissection and deep pelvic side wall anatomy. <h3>Design</h3> Case presentation. <h3>Setting</h3> Tertiary medical center. <h3>Patients or Participants</h3> 74-year-old female with history of type 2 diabetes, hypertension, and a vaginal hysterectomy with left sacrospinous ligament suspension nine years ago, presented with fever and found to have bacteremia. Abdominal and pelvic MRI showed a presacral and precoccygeal loculated collections, sacral osteomyelitis, and fistula from the left superior vaginal vault to one of the presacral collections. <h3>Interventions</h3> Laparoscopic resection of sacrospinous fistula tract. <h3>Measurements and Main Results</h3> The patient showed significant improvement in her symptoms with resolution of low back pain, vaginal discharge and bleeding. <h3>Conclusion</h3> Gentle dissection with maintained hemostasis, creating windows, and starting from less distorted anatomy are key points in retroperitoneal dissection.

Recurrence of Pain After Usual Nonoperative Care for Symptomatic Lumbar Disk Herniation: Analysis of Data From the Spine Patient Outcomes Research Trial

ObjectiveTo determine risks and predictors of recurrent leg and low back pain (LBP) after unstructured, usual nonoperative care for subacute/chronic symptomatic lumbar disk herniation (LDH). DesignSecondary analysis of data from a concurrent randomized trial and observational cohort study. SettingThirteen outpatient spine practices. ParticipantsA total of 199 participants with resolution of leg pain and 142 participants with resolution of LBP from among 478 participants receiving usual nonoperative care for symptomatic LDH. Assessment of Risk FactorsPotential predictors of recurrence included time to initial symptom resolution, sociodemographics, clinical characteristics, work-related factors, imaging-detected herniation characteristics, and baseline pain bothersomeness. Main Outcome MeasurementsLeg pain and LBP bothersomeness were assessed by the use of a 0-6 numerical scale at up to 4 years of follow-up. For individuals with initial resolution of leg pain, we defined recurrent leg pain as having leg pain, receiving lumbar epidural steroid injections, or undergoing lumbar surgery subsequent to initial leg pain resolution. We calculated cumulative risks of recurrence by using Kaplan-Meier survival plots and examined predictors of recurrence using Cox proportional hazards models. We used similar definitions for LBP recurrence. ResultsOne- and 3-year cumulative recurrence risks were 23% and 51% for leg pain, and 28% and 70% for LBP, respectively. Early leg pain resolution did not predict future leg pain recurrence. Complete leg pain resolution (adjusted hazard ratio [aHR] 0.47, 95% confidence interval [CI] 0.31-0.72) and posterolateral herniation location (aHR 0.61; 95% CI 0.39-0.97) predicted a lower risk of leg pain recurrence, and joint problems (aHR 1.89; 95% CI 1.16-3.05) and smoking (aHR 1.81; 95% CI 1.07-3.05) predicted a greater risk of leg pain recurrence. For participants with complete initial resolution of pain, recurrence risks at 1 and 3 years were 16% and 41% for leg pain and 24% and 59% for LBP, respectively. ConclusionsRecurrence of pain is common after unstructured, usual nonsurgical care for LDH. These risk estimates depend on the specific definitions applied, and the predictors identified require replication in future studies.

Proposed alternative revision strategy for broken S1 pedicle screw: radiological study, review of the literature, and case reports

Background contextThere have been many reports outlining differing methods for managing a broken S1 screw. To the authors' best knowledge, the technique used in the present study has not been described previously. It involves insertion of a second pedicle screw without removing the broken screw shaft. Study designRadiological study, literature review, and two case reports of the surgical technique. PurposeTo report a proposed new surgical technique for management of broken S1 pedicle screws. MethodsComputed tomography (CT) scans of 50 patients with a total of 100 S1 pedicles were analyzed. There were 25 male and 25 female patients with an average age of 51 years ranging from 36 to 68 years. The cephalad-caudal length, medial-lateral width, and cross-sectional area of the S1 pedicle were measured and compared with the diameter of a pedicle screw to illustrate the possibility of inserting a second screw in S1 pedicle without removal of the broken screw shaft. Two case reports of the proposed technique are presented. ResultsThe left and right S1 pedicle cross-sectional area in female measured 456.00±4.00 and 457.00±3.00 mm2, respectively. The left and right S1 pedicle cross-section area in male measured 638.00±2.00 and 639.00±1.00 mm2, respectively. There were statistically significant differences when comparing male and female S1 pedicle length, width, and cross-sectional area (p<.05). At 2-year follow-up, the two case reports of the proposed technique showed resolution of low back pain and radicular pain. Plain radiograph and CT scan showed posterolateral fusion mass and hardware in good position with no evidence of screw loosening. ConclusionsThe S1 pedicle dimensions measured on CT scan reviewed in the present study showed that it may be anatomically feasible to place a second screw through the S1 pedicle without the removal of the broken screw shaft. This treatment method will reduce the complications associated with other described revision strategies for broken S1 screws.

Increased intramuscular fatty infiltration without differences in lumbar muscle cross-sectional area during remission of unilateral recurrent low back pain

Lumbar muscle degeneration is a common feature in non-specific low back pain (LBP). It is hypothesized that degenerated muscles might compromise spinal stability and lead to further injury/pain. However, little is known about lumbar muscle morphometry after resolution of LBP. Therefore, this study investigated the extent of lumbar muscle atrophy and fatty infiltration in individuals who are at risk for a recurrence of LBP. Thirteen participants in remission of unilateral recurrent LBP were compared to 13 healthy controls, comparable for age, weight, length and level of physical activity. Total, lean muscle and fat cross-sectional area (CSA) of lumbar multifidus (MF), erector spinae (ES) and psoas (PS) were investigated on T1-weighted Magnetic Resonance Imaging (MRI), bilaterally and at 3 lumbar levels (L3 upper, L4 upper and L4 lower endplate). In addition, a muscle-fat-index (MFI) was calculated reflecting the amount of fatty infiltration in lean muscle tissue. No significant differences for total, lean muscle and fat CSA were found between people in remission of recurrent LBP and the control group. Conversely, MFI was increased bilaterally at the 2 lowest lumbar levels. There were no differences between the previously painful and non-painful side of the LBP group for any of the parameters. These results show a generalized increase in intramuscular fatty infiltration in lean muscle tissue in the absence of macroscopical signs of muscle degeneration after resolution of LBP. These findings reflect a decreased muscle quality, but not quantity, and might indicate a pathophysiological mechanism contributing to recurrence of LBP.

A manual therapy and exercise approach to meralgia paresthetica in pregnancy: a case report

Objective To present a case of a pregnant patient with meralgia paresthetica who improved using manual therapy and exercise procedures. Clinical Features A 22-year-old patient in the sixteenth week of pregnancy had low back pain, bilateral anterolateral thigh paresthesia and groin pain for a duration of 1 month. She had no motor deficits in either lower extremity and her reflexes were intact. As a standard clinic procedure, a battery of functional tests were performed including: active straight leg raise, long dorsal ligament test, and the pelvic pain provocation procedure. Based on her clinical history and physical responses to the aforementioned functional tests, the diagnosis of meralgia paresthetica was deduced. Intervention and Outcome Treatment was provided at 6 visits over a 6-week period where the patient underwent evaluation, manual intervention, and exercise prescription. Active Release Technique (ART) was performed to the restricted right sacroiliac (SIJ) complex and quadratus lumborum muscles. ART and post-isometric relaxation were applied to the illiopsoas muscles. The home exercise program consisted of pelvic/low back mobility, stabilization and relaxation exercises. After 6 treatments, the patient reported complete resolution of low back pain and left lower extremity symptoms and a 90% improvement in the right thigh symptoms. At her one-year follow-up, the patient reported no further complications and the absence of pain. Conclusions Manual therapy and exercises may serve as an effective treatment protocol for pregnant patients experiencing low back pain complicated by paresthesia. Because these conservative procedures offer a low-risk intervention, additional clinical studies are warranted to further study this treatment.

Surgical management for low back pain. Rationale and indication

Various spinal diseases that cause low back pain have two distinct pathologies, including mechanical disruption of the spinal column and compression of the cauda equina and the nerve roots. Although, the advancement in surgical techniques has brought satisfactory neural recovery, resolution of low back pain still remains unpredictable. The development of low back pain is affected by psychosocial factors besides pathological lesions in the lumbar spine leading to functional impairment. Surgical indication for low back should be carefully decided considering such nonorganic aspects of low back pain.