Superficial Tenderness Research Articles

Nonorganic (Behavioral) Signs and Their Association With Epidural Corticosteroid Injection Treatment Outcomes and Psychiatric Comorbidity in Cervical Radiculopathy: A Multicenter Study

ObjectiveTo determine the association between cervical nonorganic pain signs and epidural corticosteroid injection outcomes and coexisting pain and psychiatric conditions. Patients and MethodsSeventy-eight patients with cervical radiculopathy who received epidural corticosteroid injection were observed to determine the effects that nonorganic signs have on treatment outcome. A positive outcome was a decrease of 2 or more points in average arm pain, coupled with a score of 5 on a 7-point Patient Global Impression of Change scale 4 weeks after treatment. Nine tests in 5 categories (abnormal tenderness, regional disturbances deviating from normal anatomy, overreaction, discrepancies in examination findings with distraction, and pain during sham stimulation) were modified from previous studies and standardized. Other variables examined for their association with nonorganic signs and outcomes included disease burden, psychopathology, coexisting pain conditions, and somatization. ResultsOf the 78 patients, 29% (n=23) had no nonorganic signs, 21% (n=16) had signs in 1 category, 10% (n=8) had signs in 2 categories, 21% (n=16) had signs in 3 categories, 10% (n=8) had signs in 4 categories, and 9% (n=7) had signs in 5 categories. The most common nonorganic sign was superficial tenderness (44%; n=34). Mean number of positive nonorganic categories was higher in individuals with negative treatment outcomes (2.5±1.8; 95% CI, 2.0 to 3.1) compared with those with positive outcomes (1.1±1.3; 95% CI, 0.7 to 1.5; P=.0002). Negative treatment outcomes were most strongly associated with regional disturbances and overreaction. Positive associations were noted between nonorganic signs and multiple pain (P=.011) and multiple psychiatric (P=.028) conditions. ConclusionCervical nonorganic signs correlate with treatment outcome, pain, and psychiatric comorbidities. Screening for these signs and psychiatric symptoms may improve treatment outcomes. Trial RegistrationClinicalTrials.gov identifier: NCT04320836.

Digital gangrene in spinal tuberculosis

Though tuberculosis (TB) is commonly seen, peripheral gangrene as a manifestation of TB is not common. Spinal TB presents with backache, paraparesis, or quadriparesis with or without bladder and bowel involvement. It may cause spinal deformities. However, peripheral gangrene is not a common manifestation of spinal TB. Here, we present the case of spinal TB, with peripheral gangrene in a 30-year-old female. There was blackening and shrinkage of the left third toe, with superficial tenderness, darkening, and loss of sensation over the left fourth and fifth toes. Tuberculin test and Mantoux test were positive. The magnetic resonance imaging findings were suggestive of Pott’s spine. Arterial Doppler of the affected lower limb revealed sluggish flow, as suggested by the biphasic waveform. The patient was started on antituberculous treatment. Although the neurological symptoms improved with antituberculous treatment, the peripheral gangrene resolved only partially and required amputation.

Screening of Foot at Risk in Diabetic Patients

Introduction: The term “diabetic foot” refers to all conditions that affect the foot and are directly related to the impact of diabetes. Objective: Screen the foot at risk in diabetic patients at the hospital of Mali. Methods: It was a cross-sectional study from January 1st, 2016 to June 30, 2016, at the Department of Internal Medicine and endocrinology of the Hospital of Mali. It was focused on all hospitalized diabetic patients. Results: Thirty-two (32) patients had a foot at risk among 76 diabetic patients during the study period representing 42.10%. The sex ratio was 0.52. Type 2 diabetes accounted for 82%. A glycemic imbalance (HBA1C > 7%) was observed in 88.15%. Eighteen percent (18%) of patients had a history of ulceration or amputation; 33% were walking barefoot; 78.9% had tingles in the foot; 31.6% had intermittent claudication; 64.5% had foot cleanliness; 8% claw toes; 42% had abolition or reduction of superficial tenderness to monofilament and 21% had mixed foot (neuropathy + arteriopathy). In our study, 58.9% of patients had no risk of podiatry. Conclusion: Screening of foot at risk is essential in the management of diabetes because it determines the podiatric risk enabling to minimize future functional disabilities.

Carnett’s Legacy: Raising Legs and Raising Awareness of an Often Misdiagnosed Syndrome

Nearly 90 years ago, John Carnett, a Philadelphia surgeon, wrote that chronic right-sided abdominal pain resulting in appendectomy actually originated in the abdominal wall, naming it ‘‘intercostal neuralgia.’’ He detailed the physical findings, including pinch tenderness of a skin/subcutaneous fat fold, cutaneous hyperesthesia at the painful site, and, remarkably, focal tenderness when the abdominal muscles are relaxed and when voluntarily tensed by raising the head or straightened lower extremities off the examination table, now known as a positive Carnett test or Carnett sign [1]. The disorder he described, abdominal wall pain (AWP), has been recognized subsequently to originate anywhere in the abdomen, especially in the lateral border of the rectus abdominis or in a surgical scar, and may occur at multiple sites [2, 3]. A commonly proposed pathophysiology is abdominal cutaneous nerve entrapment (ACNE), chiefly involving the anterior cutaneous branch of a lower thoracic subcostal nerve [4]. The term AWP also sometimes encompasses other nonvisceral disorders, including hernias, thoracic radiculopathy, and myofascial, costal margin, and xiphoid pain [5]. I limit the term AWP to designate what Carnett described, which some authors term ACNE. Experienced physicians accurately predict many cases when a patient, usually a woman, initially says ‘‘I have a constant pain right here,’’ pointing to a spot on her abdomen with one or two fingers. Carnett emphasized the examiner should maintain finger pressure at the tender site when the patient raises the head or legs. For a positive Carnett test, Greenberg and colleagues require increased tenderness with muscle tensing, not just Carnett’s ‘‘almost or quite as much’’ criterion [2]. Their AWP diagnostic criteria are: (1) localized pain or a fixed location of tenderness and (2) superficial tenderness or point tenderness B2.5 cm in diameter or a positive Carnett test. Pain relief after injection of a local anesthetic confirms the diagnosis [2]. I routinely assess tenderness when patients separately elevate their head and legs, as some report increased tenderness by only one of these maneuvers. After reviewing follow-up studies, Greenberg’s group concluded that by adhering to their diagnostic criteria and by following patients over time, visceral causes of pain would seldom be missed [2]. Warning signs are important; for example, 4 (2.9 %) of 137 cases I diagnosed at Kaiser Permanente Southern California were subsequently diagnosed with a visceral source, of whom 3 had unintentional weight loss [3]. Despite the simplicity and accuracy of physical diagnosis, AWP is widely unrecognized: It is suspected by few referring physicians among my patients [3] and in other series [2]. Gastroenterologists and medical residents often overlook the diagnosis [2]; [85 % of surveyed surgeons and residents had not heard of ACNE [6]. Although information on the prevalence and the healthcare costs of AWP and ACNE is limited by underdiagnosis, AWP is commonly diagnosed as a cause of abdominal pain in patients referred to gastroenterologists and to chronic pain clinics [2]. A female predominant syndrome, AWP comprised 7.8 % of symptomatic referrals to me at Kaiser, nearly 50 % the rate of referral for irritable bowel syndrome (IBS) [3]. Patient characteristics included 45.8 % overweight (body mass index [BMI] 25–29.9 kg/ m), 38.1 % obese (BMI[ 30 kg/m) and chronic low back pain, gastroesophageal reflux disease, IBS, and depression, each affecting over 20 % of patients [3]. Dutch & George F. Longstreth gflongstreth@gmail.com

Syndrome of severe pain associated with a continuous bumetanide infusion

Syndrome of severe pain associated with a continuous bumetanide infusion

Importance of a Physical Examination for Efficient Differential Diagnosis of Abdominal Pain: Diagnostic Usefulness of Carnett's Test in Psychogenic Abdominal Pain

Abdominal pain can be a challenging complaint for both primary care and specialist physicians because it is frequently a benign complaint, but it can also herald a serious acute clinical condition. An epidemiologic assessment of acute abdominal pain is classified in outpatients complaining of abdominal pain on their first visit to primary care physicians including the following: whole abdominal, epigastric, right subcostal, left subcostal, right flank, left flank, periumbilical, right-lower, mid-lower, and left lower pain (1). Abdominal pain can be categorized as follows: intra-abdominal pain, abdominal wall pain, and referred pain. Patients are often subjected to a variety of procedures in an attempt to find a cause for the abdominal pain. Failure to find a visceral cause for the pain may prompt the physician to apply a functional or psychosomatic label to the patient, with any treatment directed along those lines. However, awareness that abdominal pain may have a non-visceral origin can forestall a fruitless search for intra-abdominal pathology. Abdominal wall pain is most commonly diagnosed on the basis of a patient’s history and a physical investigation. A careful history and examination, and noticing symptoms arising from abdominal wall pain, might lead to an accurate diagnosis and appropriate treatment, and it could avoid negative examinations (2-5). Carnett’s test is a clinical test in which abdominal tenderness is evaluated. It is useful for differentiating abdominal wall pain from intra-abdominal pain. While supine, the patient is asked to perform a straight-leg-raising maneuver while the examiner’s hand touches the painful site. Raising only the head while in the supine position achieves the same purpose. These maneuvers tighten the rectus abdominis muscles, increasing the pain from the entrapped nerve. True visceral sources of pain are associated with less tenderness when abdominal muscles are tense (2, 6). A previous study reported that Carnett’s test has a sensitivity of 81% and a specificity of 88%. The constant site of tenderness has the highest sensitivity (97%) but the lowest specificity (54%), whereas superficial tenderness has the highest specificity (90%) with a sensitivity of 84%. Another study, proposed criteria for diagnosing abdominal wall pain, and tested 33 patients with abdominal wall pain compared with 62 patients with intra-abdominal pain; they found a sensitivity of 85% and specificity of 97%, which appeared to be better than those for the Carnett’s test alone (9). This suggests that clinical methods are sufficient to diagnose abdominal wall pain in most cases and can be used to rule out other possible diagnoses (Table 1) (7-11). If Carnett’s test is positive, pain relief after an accurately placed nerve block or trigger point anesthesia injection can lead to diagnostic therapy. Pain relief with anesthesia injection affords excellent reassurance to the patient when effective (3, 12, 13). Carnett’s test may not be interpretable in patients who cannot adequately comply with leg or head-raising maneuvers. False positive results may occur from visceral causes of pain that involve the local parietal peritoneum (14). Psychogenic abdominal pain is inextricably linked to the origin of pain. The pain is often described as severe and persistent, having been experienced for several years and being constantly present. The pain is consistent with the anatomy of the nervous system, and no organic pathological or pathophysiological mechanism can be classified to the physical findings. Patients usually appear well compared with intra-abdominal patients (15, 16). In this issue of Internal Medicine, Takada et al evaluated the diagnostic usefulness of Carnett’s test for psychogenic abdominal pain, which was established by a retrospective study in 5,399 outpatients with abdominal pain. The differentiation of psychogenic abdominal pain from intra-abdominal pain has not yet

Demonstration of necrotizing fasciitis on Ga-67 scans in a patient with systemic lupus erythematosus.

A 17-year-old girl with a history of systemic lupus erythematosus with lupus nephritis for 6 years was found to have progressive superficial tenderness over the medial aspect of the right thigh. In addition, darkening of the skin of the right thigh with an ecchymosis-like appearance developed in the following hours. Ga-67 scans performed to evaluate inflammation of the skin revealed increased uptake in the involved areas. Skin biopsy was performed, and the pathologic diagnosis was necrotizing fasciitis.

Chronic abdominal wall pain: a frequently overlooked problem. Practical approach to diagnosis and management.

Chronic abdominal wall pain is frequently misdiagnosed as arising from a visceral source, often resulting in inappropriate diagnostic testing, unsatisfactory treatment, and considerable cost. Its prevalence in general medical practice is unknown, although it may account for about 10% of patients with chronic idiopathic abdominal pain seen in gastroenterological practices. The most common cause appears to be entrapment of an anterior cutaneous branch of one or more thoracic intercostal nerves; myofascial pain and radiculopathy are less frequent. Sharply localized pain and superficial tenderness are suggestive of abdominal wall origin. Carnett's test (accentuated localized tenderness with abdominal wall tensing) is a helpful diagnostic sign, especially when incorporated with other findings. Early exclusion of a parietal source should increase diagnostic accuracy when evaluating patients with chronic abdominal pain. Reassurance of patients by the correct diagnosis and avoidance of precipitating causes is often sufficient treatment. However, accurately placed anesthetic/corticosteroid injections give substantial pain relief to more than 75% of patients, often for prolonged periods, and may be confirmatory for the source of the complaint. The probability of missing visceral disease is small (probably less than 7%) with strict adherence to diagnostic criteria and diligent observation of patients.

Increased movement pain in osteoarthritis of the hands is associated with Aβ-mediated cutaneous mechanical sensitivity

The relationship between joint pain and hyperalgesia has been explored in animal models of articular inflammation, but is yet to be shown in the most common rheumatologic condition: osteoarthritis. In this study, cutaneous thermal and mechanical pain thresholds were measured over the thumb of patients with osteoarthritis of the hands. In symptomatic patients, pain was manipulated through resisted active movement of the thumb. Provocation of movement pain (MP) was associated with a sustained fall in mechanical pain thresholds. Thermal pain thresholds remained stable during increases in joint pain. Increased mechanical sensitivity after exacerbation of MP was alleviated by Aβ fiber blockade. It appears that superficial tenderness over the osteoarthritic thumb fluctuates with pain arising from movement of the joint. It is concluded that dorsal horn mechanisms contribute to MP-related hyperalgesia in osteoarthritis of the hands.

Vulvar vestibulitis syndrome: a clinico‐pathological study

Twenty four patients with the vulvar vestibulitis syndrome formed the basis of this clinicopathological study. Entry dyspareunia was the constant presenting complaint and vestibular erythema with acute superficial tenderness the invariable clinical finding. In our series there was a marked predominance of Caucasians, patients were most often of social classes I and II and most frequently in the third decade. The results of laboratory investigation revealed that this syndrome has a diverse range of potential aetiologies including vulval infections, dysplasia and in one instance acute vasculitis.