Simple Back Pain Research Articles

Spontaneous spinal epidural hemorrhage due to polycythemia vera

Spontaneous spinal epidural hematoma (SSEH) as an initial presentation of polycythemia vera (PV) is rare. It can present with the features ranging from simple back pain to complete paraplegia depending on the site of the spinal compression. Herein, we describe a case of undiagnosed PV presented as back pain with radiation to the chest wall in a 46-year-old male patient and subsequently diagnosed with spontaneous spinal epidural hemorrhage. To the best of our knowledge, only one case of spinal epidural hematoma-related PV has been reported so far. Emergent decompressive laminectomy was done within 10 h of initial presentation with excellent clinical outcome. Therefore, this condition must be promptly diagnosed and treated with decompression surgery to minimize the risk of neurological complication.

Lumbar Canal Stenosis: A Prospective Clinicoradiologic Analysis.

Although spinal canal narrowing is thought to be the defining feature for the clinical diagnosis of lumbar canal stenosis, the degree of spinal canal stenosis necessary to elicit neurologic symptoms is not clear. Several studies have been performed to detect an association between a narrow spinal canal and clinical symptoms. Through our prospective study, we compared the radiologic criteria with the clinical criteria using the Oswestry Disability Index (ODI) and assessed how they correlate. We used the qualitative grading (morphological classification system on magnetic resonance imaging [MRI]) system, dural sac cross-sectional area (DSCA), and sedimentation sign on MRI images and compared them with the Self-Paced Walking Ability (Self-Paced Walking Test) and ODI of the patients in the study. The systems were applied to 85 patients divided into three groups: group A: 43 patients with neurogenic claudication and able to walk < 30 minutes; group B: 11 patients with neurogenic claudication and able to walk > 30 minutes; and group C: 31 patients with simple back pain and no signs of neurologic claudication. The mean ODI was 21.19 in group C, 46.50 in group B, and 61.95 in group A. The difference was statistically significant. The mean DSCA was 164.42 mm2 in group C, 49.94 mm2 in group B, and 35.07 mm2 in group A. The difference was statistically significant. The sedimentation sign was negative in 96.8% patients in group C, 54.5% patients in group B, and 32.6% patients in group A. The difference was statistically significant. Group C had 9.3% patients in morphology grade A3, 51.6% in grade A2, and 38.7% patients in grade A1. Group B had 63.6% patients in grade C, 18.2% patients in grade B, 9.1% in grade A4, and 9.1% in grade A3. Group A had 18.6% patients in grade D, 39.5% in grade C, 27.9% in grade B, 11.6% in grade A4, and 2.3% in grade A3. The mean DSCA of group C was significantly different from group A and group B, but the difference of the mean DSCA between group A and group B was not statistically significant. The relationship of ODI to DSCA, ODI to sedimentation sign, and ODI to morphological grading for group C and group A was not statistically significant. The relationship of morphological grading to DSCA was statistically significant for all three groups. DSCA, morphological grading, and sedimentation sign are good to excellent radiologic indicators differentiating patients with simple back pain from those with lumbar spinal stenosis. Clinically, ODI is an excellent indicator of the severity of stenosis. But ODI statistically has no significant correlation to any of these radiologic parameters.

Spinal tuberculosis: A systematic review of case studies and development of an evidence-based clinical guidance tool for early detection.

Despite research being done on spinal tuberculosis, diagnosing this condition at an early stage remains problematic due to its insidious onset and the varying symptoms being associated. Most individuals present to the health care facility with either simple back pain at an early stage or neurological complications at a later stage, when spinal compression and vertebral collapse have occurred as a result of delayed diagnosis. The prevention of secondary complications is therefore dependent on early recognition and diagnosis. The objective of this review was to identify common clinical patterns in case presentations and develop an evidence-based clinical guidance tool to assist clinicians in the early identification of spinal tuberculosis. A comprehensive literature search was conducted for published spinal tuberculosis case studies, which yielded 28 cases after critical appraisal. Data from the studies were categorized in order to assist with a factor analysis and the development of an evidence framework for screening and diagnosing spinal tuberculosis. An evidence-based clinical guidance tool was then designed from the data obtained. Factors associated with spinal tuberculosis and frequently reported symptoms and physical signs with which the patient could present upon assessment were identified. Options for investigations at primary, secondary, and tertiary levels were also identified. Through the use of an evidence-based clinical guidance tool, the clinician could be guided in the early suspicion and management of individuals with spinal tuberculosis and prevention of secondary complications.

The Use of Lumbar Spine Magnetic Resonance Imaging in Eastern China: Appropriateness and Related Factors.

Back pain is common and costly. While a general scene of back pain related practice in China remains unknown, there are signs of excessive use of lumbar spine magnetic resonance (MR). We retrospectively studied 3107 lumbar spine MRIs in Eastern China to investigate the appropriateness of lumbar spine MR use. Simple back pain is the most common chief complaint for ordering a lumbar MR study. Only 41.3% of lumbar spine MR studies identified some findings that may have potential clinical significance. Normal lumbar spine is the most common diagnosis (32.7%), followed by lumbar disc bulging and lumbar disc herniation. Walk difficulties, back injury and referred leg pain as chief complaints were associated with greater chance of detecting potentially clinically positive lumbar MR image findings, as compare with simple back pain. There was no difference in positive rates among orthopedic surgeon and specialists of other disciplines. Lumbar spine MR imaging was generally overused in Eastern China by various specialists, particularly at health assessment centers. For appropriate use of lumbar spine MR, orthopedic surgeons are no better than physicians of other disciplines. Professional training and clinical guidelines are needed to facilitate evidence-based back pain practice in China.

Comparative Analysis of Global Spine Alignment using Whole Spine CT and X-Ray: Correlative Analysis of Reciprocal and Physiologic Changes of the Cervical Alignment

Objective The aims of this study were to compare the parameters of spinal sagittal alignment between whole spine computed tomography (CT) scans in supine position and whole spine X-ray in standing position, and also to analyze the reciprocal and physiologic changes of the cervical spine in dynamic motion. Methods Data were obtained retrospectively in a single hospital. Radiographic data of 55 subjects were recruited about whole spine CT, whole spine X-ray, and cervical dynamic X-ray from November 2007 to May 2014. The mean age was 52.8 year (range, 17–85 years) and the female:male ratio was 31:24. Whole spine CT was checked in supine position and whole spine X-ray was checked in standing position. Cervical dynamic X-ray was checked in standing position. We included the subjects only with mild degenerative disease and simple back pain and excluded the subjects with severe scoliosis, severe deformity, and operation history. The radiological sagittal parameters on lateral paragraph were evaluated including C0–C7 Cobb angle (C0C7), C0–C2 Cobb angle (C0C2), C2–C7 Cobb angle (C2C7), T1 slope (T1S), neck tilt (NT), thoracic inlet angle (TIA), C2 tilt (C2T), C7 tilt (C7T), C2 sagittal vertical axis (C2SVA), C7 sagittal vertical axis (C7SVA), T1–T12 Cobb angle (T1T12), T1–T7 Cobb angle (T1T7), T7–T12 Cobb angle (T7T12), L1–S1 Cobb angle (L1S1), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI). Each parameter was analyzed statistically with paired t test between CT and X-ray, and also assessed the relationships between all parameters with the Pearson correlation analysis. Results All corresponding parameters of spine alignment on X-ray were significantly correlated with those on CT. There was no significant difference in TIA (0.62 ± 3.41) and PI (0.62 ± 3.55) between CT and X-ray ( p &gt; 0.05). However, cervical lordosis, T1 slope (T1S), thoracic kyphosis, and lumbar lordosis (L1S1) on X-ray were significantly larger than those on CT. The differences of the means were 21.3 ± 15.6 degrees in C0C7, 3.8 ± 9.5 degrees in C0C2, 17.5 ± 12.3 degrees in C2C7, 7.8 ± 11.3 degrees in T1S, 14.3 ± 9.8 degrees in T1T12, 9.1 ± 8.4 degrees in T1T7, 5.2 ± 9.0 degrees in T7T12, and 4.8 ± 17.1 degrees in L1S1 ( p &lt; 0.05). Age significantly correlated with TIA ( r = 0.382). Thoracic kyphosis (T1T12) had the significant correlation with T1S ( r = 0.874 on CT, r = 0.425 on X-ray) and cervical lordosis (C0C7; r = 0.455 on CT, r = 0.405 on X-ray). Cervical tilt (C2T) and SVA (C2SVA) also had the significant correlations with T1S (C2T: r = − 0.570 on CT, r = − 0.550 on X-ray; C2SVA: r = 537 on CT, r = 0.498 on X-ray). T1S had the significant correlations with the TIA ( r = 0.414 on CT, r = 0.368 on X-ray). T1S also had the significant correlations with cervical lordosis (C0C7: r = 0.367 on CT, r = − 0.469 on X-ray), which mainly correlated with subaxial spine (C2C7: r = 0.355 on CT, r = 0.404 on X-ray) and not with upper cervical spine (C0C2). The changes of the cervical lordosis (C0C7) in dynamic motion (neutral, flexion, and extension) had highly evident correlations with subaxial spine (C2C7) than with upper cervical spine (C0C2). Pearson correlation coefficients ( R) between C0C7 and C2C7 were 0.810 in neural, 0.766 in flexion, and 0.740 in extension, respectively ( p &lt; 0.01). Conclusion The difference of spine alignment between CT and X-ray should be because of the difference of the gravity stem from the posture. Upright posture may increase thoracic kyphosis, and cervical lordosis sequentially and reciprocally. Physiologic motions in the spine cause the cervical accommodations, in which subaxial spine is mainly and initially responsible for the reciprocal changes to other spinal parameters such as TIA and T1 slope. This finding may be the main reason of the subaxial cervical spine degeneration.

(i) Optimizing non-operative care

Summary Surgical treatment of back pain has limited success. It is therefore critical that spinal surgeons (who see most back problems in secondary care) are aware of the results of non-operative treatments. It is now known that most of the predictors of the development of long term distress and disability following an episode of back pain are psychosocial. Factors such as a tendency to low mood, fear avoidance, passivity, and poor sickness absence record, (known as "yellow flags"), all feed into the pain experience and thus should be included in the work up. Detection of multiple factors can inform the surgeon about why the person is in trouble and enable better decision making about the likelihood of a biological intervention being successful. Of the non-operative treatments available, although there is limited evidence for exercise programmes and back schools, many commonly employed approaches such as passive physiotherapy and facet joint injections are of unproved benefit. The treatments with best evidence of effectiveness are intensive interdisciplinary programmes (also known as functional restoration or pain management programmes). These therapies have been shown to be as effective as spinal fusion surgery and should be offered to persons with persistent difficulties before proceeding to fusion surgery.

Aetiology of low back pain in Mulago Hospital, Uganda.

Low back pain exists in epidemic proportions in the western world and is on the increase. Its cause is mostly nonspecific. Not much is known about it in the developing world because the data is scanty. This study was set out to investigate the possible causes of low back pain and prevalence. To establish the likely causes of low back pain among patients seen in the out patient department, Mulago Hospital, Uganda. 204 patients were enrolled out of 1033 general patients who were present to the out patient referral hospital orthopedic clinic. All the 204 were referred patients with low back pain as the chief complaint. They were subjected to a questionnaire, which included history taking, a physical examination and investigations. Data was entered using Epi info soft ware and analyzed using SPSS. The prevalence was 20%. The mean age was 47 years 10 months. The majority, 62.3% of patients had mechanical or simple back pain with no definable patho-anatomic causative factor (non-specific). 19.1% had nerve root compression due to prolapsed intervertebral discs. 17.2% had serious spinal pathology due to tuberculosis, brucellosis, fractures and degenerative changes. For 3 patients (1.5%) the cause was not determined. The findings indicate that low back pain of non-specific aetiology is the commonest cause of back pain. The precise aetiology of this large indefinite entity warrant further study.

Individual Active Treatment Combined With Group Exercise for Acute and Subacute Low Back Pain

Randomized controlled trial. To compare two fast-access evidence-based interventions for the treatment of simple low back pain. People aged 18-65 with a new episode of simple back pain causing them to be off work or on modified work for less than 1 year. A district general hospital using a consultation/treatment room and a rehabilitation gym. One group received a back advice booklet and one session of advice and then followed the normal route of care as directed by their general practitioner. The other group received the back booklet and one session of advice and also a back program. The back program consisted of a full assessment, immediately followed by one individual treatment, and then exercise classes over 1 to 2 weeks. (1) Rate of return to work, (2) pain scores and health status, and (3) cost effectiveness of interventions versus the financial cost to the individual or employer. On average, those receiving the individual treatment and group exercise took 7 days less off work. This represented a 35% reduction in the amount of time taken off work since study entry. The estimated cost saving of providing the extra service of a simple back program ranged between 250 pound (367 US dollars, 300 euro) and 578 pound (850 US dollars, 694 euro) for each patient. The results indicate that the costs of this active back program are more than reimbursed as a consequence of earlier return to work.

The effect of osteopathy in the treatment of chronic low back pain – a feasibility study

Introduction Osteopaths commonly treat back pain. Evidence of effectiveness is limited. We describe a feasibility study for a pragmatic randomised controlled trial of an osteopathic approach for treating patients with chronic low back pain. Method We recruited participants with chronic low back pain from one general practice. Those randomised to treatment received up to eight treatments, the control participants received usual care from their general practice. The primary outcome measure was the Roland Morris Disability Questionnaire. Follow up was by postal questionnaire 3 and 6 months after randomisation. Results We approached 15 patients; of which nine were recruited to the study. We recruited two participants for each 1000 registered patients at our pilot practice. Participant feedback from those randomised to treatment was positive; all of them reported some benefit from the treatment. Follow up rates were poor (30% at 3 months). Discussion Despite some practical difficulties administering the study at a general practice level, we have shown that recruitment adequate to achieve good statistical power for such a trial is feasible. We estimate that 1.7 participants with appropriate inclusion criteria per 1000 registered patients from each general practice could be recruited into the trial. Thus, recruiting from 20–30 general practices should provide 200 recruits for a randomised controlled trial. The intervention was reported as being of benefit. Conclusion A randomised controlled trial comparing an osteopathic approach to the management of chronic simple back pain to usual general practice care is feasible with the collaboration of two Primary Care Trusts.

Comparing Treatments for Back Pain

The relative efficacy of various physical treatments for people with back pain is unknown. British investigators conducted this large randomized trial to compare several interventions. Researchers recruited 1334 patients (mean age, 43) from 181 general practices. All patients had experienced at least 4 weeks of simple back pain; this definition excluded patients …

Treatment of low back pain--significance, principles and danger

Today, a wide range of efficient analgesic and non-analgesic drugs for the treatment of back pain are available. However, drugs should never be the only mainstay of a back pain treatment program. Non-steroidal antiinflammatory drugs (NSAID) are widely used in acute back pain. NSAIDs prescribed at regular intervals are effective to reduce simple back pain. The different NSAIDs are effective for the reduction of this pain. They have serious adverse effects, particularly at high doses, in the elderly, and on long-term administration. The new cyclooxygenase II-inhibitors have less gastrointestinal complications. But the long-term experiences are limited up to now. Considerable controversy exists about the use of opioid analgesics in chronic noncancer pain. Many physicians are concerned about the effectiveness and adverse effects of opioids. Other clinicians argue that there is a role for opioid therapy in chronic noncancer pain, e. g. especially in chronic low back pain. There is a low incidence of organ toxicity in patients who respond to opioids. The incidence of abuse and addiction is likewise relatively low. The potential for increased function and improved quality of life seems to outweigh the risks. However, there is a lack of randomised controlled trials (RCT) on opioid therapy in a multimodal pain treatment approach. Clinical experience and some studies suggest administration of sustained release opioids because of better comfort for the patient and less risks for addiction. The opioids should be selected due to the specific side effects of the different drugs. For patients with pre-existing constipation transdermal fentanyl should be preferred. Antidepressant medications have been used for the treatment of chronic back pain, though there is only little scientific evidence for their effectiveness. There is no evidence for the use of antidepressants in acute low back pain. Trials of muscle relaxants for patients with acute back pain have used a wide range of agents, e. g. benzodiazepines. They mostly reduce acute back pain, but they have significant adverse effects including drowsiness and psychological and physical dependence even after relatively short treatment. Benzodiazepines are not indicated in the treatment of chronic back pain. Drugs are sometimes necessary for the patients to begin and persevere a multimodal treatment program. Drug therapy should be terminated as soon as other treatment strategies succeed. Unfortunately, no studies exist evaluating the place of analgesics within a multimodal treatment program.

Simple back pain: is it so simple?

Val Jackson highlights problems associated with back pain and considers actions to be taken in the event of an episode of back pain.

Non-attendance for Social Security medical examination: patients who cannot afford to get better?

This paper reports results from a cross-sectional study of 290 consecutive Invalidity Benefit cases in the north-west of England referred to the Benefits Agency Medical Service in 1994. The hypothesis is that socio-economic factors, such as high locality unemployment rates, may be implicated, not only in the initial causation of ill health, but also in its continuance, by giving incentive to the ongoing adoption of the sick role. Results showed that residence in Liverpool, a diagnosis of anxiety/depression or simple back pain, and age under 40 years were all significantly related to non-attendance (P < 0.01). Claimants from Liverpool were also younger, overall, more likely to be called for examination, but less likely to be found fit for work if they attended. This suggests that some claimants may not attend examination because they fear being found fit for work and losing the benefit on which they and their families depend.

Low back pain

Low back pain is a common reason for physician visits and is associated with enormous costs to health care and industry. Radiographic abnormalities of the lumbar spine, including disk protrusion, are common in asymptomatic subjects and only loosely associated with symptoms and neurologic examination. Therefore, highly selective evaluation is required to avoid subjecting patients with back pain to unnecessary tests and surgical procedures. Reassurance about the favorable prognosis of low back pain is an important component of therapy. Most patients with simple back pain recover with symptomatic treatment. Plain radiographs are indicated for evaluation of patients with radiculopathy and those with risk factors for underlying medical conditions. The majority of patients with back pain, even those with radiculopathy, improve with conservative management and surgery is unnecessary. Surgical consultation and CT or MR imaging scans are indicated for patients with persistent or progressive neurologic deficits or persistent sciatica with nerve root tension signs. Acute radiculopathy with bilateral neurologic deficits, saddle anesthesia, or urinary symptoms is suggestive of cord compression or cauda equina syndrome and requires urgent surgical referral.

Nucléotomie percutanée lombaire Résultats de 196 nucléotomies chez 154 patients opérés entre 1989 et 1992

196 nucleotomies done between 1989 and 1992 gave 49 % good results. Study was prompted by the evolution of low back and lumbar root pain and their effect of daily activities. Patients were not selected as we did not set out to create a specific series. Studying sub-groups allowed us to refine the indications of percutaneous lumbar nucleotomy, showing especially the bad result in worker's compensation cases (only 31% good), contrasting with the good results (78%) in those patients with simple back pain. If technically impossible a long acting steroid injection (Celestene) was injected, giving 45% good results. Complications were rare (3%). These results are similar to those already published in those series which were not pre-selected. We continued to believe in the value of this technique while mindful of the contra-indications. This non-selected series allows us to suggest this procedure for patients resistent to different conservative treatments, but who do not require classical surgery.