Spinal disorders in childhood I: painful disorders

Back pain and spinal deformity are the most common presenting complaints of spinal disorders in childhood seen in a specialist orthopaedic spinal clinic. Many of the patients referred will have non-specific back pain, yet there are a multitude of significant and sinister pathologies of the spine along with extraspinal causes that should be considered and sought. Similarly most deformities will be either minor or idiopathic, yet specific underlying causes need to be excluded. The cornerstone of safe practice is a detailed, thorough and targeted history and examination. This article focuses on painful disorders.     

Chronic spinal disorders and psychopathology. research findings and theoretical considerations.

BACKGROUND CONTEXT: Numerous studies have documented a strong association between chronic spinal disorders and psychopathology. However, there have been methodological shortcomings associated with much of this. PURPOSE: This article reviews the relevant research literature, including methodological refinements that have resulted in improved measurement of psychopathology, in order to provide the most updated conclusions concerning the links between spinal disorders and psychopathology. STUDY DESIGN: A systematic review of all Medline referenced articles on this subject during the past three decades. METHODS: Previous research has shown that chronic spinal disorders are most often associated with depressive disorders, somatoform disorders, anxiety disorders, substance use disorders, and personality disorders. In addition to reviewing this research, the relationship between chronic spinal disorders and depressive disorders is examined in more detail. RESULTS: Although the relationship between spinal disorders and psychopathology is complex, a diathesis-stress model is emerging as the dominant overarching theoretical model. In this model, diatheses are conceptualized as pre-existing semidormant characteristics of the individual before the onset of chronic spinal disorders, which are then activated by the stress of this chronic condition, eventually resulting in a diagnosable depressive disorder. CONCLUSIONS: In the present review, a diathesis-stress model was applied specifically to the relationship between chronic spinal disorders and depressive disorders. Such a model may also be applicable to the relationship between chronic spinal disorders and other types of psychopathology, such as anxiety and substance use disorders. However, conclusive empirical support will require a prospective research design, given that these diatheses could be validly assessed only before the onset of the chronic pain condition.     

Classification of patellofemoral disorders

Patellofemoral disorders represent a large portion of the average orthopedist's practice. Despite the improvements in patellofemoral radiographs and arthroscopic diagnostic techniques, these disorders are too frequently misunderstood and frustrating to treat. This report proposes a clinical classification for patellofemoral disorders that, it is hoped, will aid our understanding and improve our results of treatment. A major feature of this classification is the recognition that a developmental and familial abnormality, patellofemoral dysplasia, is the etiology for most patellofemoral disorders. Equally important is the assignment of chondromalacia patellae to a secondary position for the most part. Other causes of anterior knee pain and disability are included to complete the classification.     

Algorithm for salvage surgery of the lumbar spine

An explicit and effective plan for evaluation of the failed back allows the diagnosis of nonorthopedic causes for low back pain, whether they be medical or psychosocial in nature. This plan includes the prompt recognition and treatment of those problems which are surgically remediable, such as the recurrent disk herniation or spinal stenosis. Finally, this plan will accurately define those patients for whom there is no cure at the present time, such as those with arachnoiditis and those with low back pain without a definable cause. Careful adherence to this plan will prevent the physician from advising these unfortunate patients who already suffered one unsuccessful operation from undergoing yet another futile exercise and yet not exclude those who will benefit from operative intervention.     

Prevalence of neuropathic pain in cases with chronic pain related to spinal disorders

Background

The incidence and characteristics of neuropathic pain associated with spinal disorders have not yet been fully clarified. The purpose of this study was to investigate the prevalence of neuropathic pain and the degree of deterioration of quality of life (QOL) in patients with chronic pain associated with spinal disorders who visited orthopedic outpatient clinics.

Methods

This cross-sectional study was conducted in 1,857 patients recruited from 137 medical institutions nationwide. Participants were men and women aged 20–79 years with a history of spine-related pain for at least 3 months and a visual analog scale (VAS) score of at least 30 in the previous week. Patients were screened using a neuropathic pain screening questionnaire. The degree of QOL deterioration and its correlation with the presence of neuropathic pain were assessed using the Short Form Health Survey with 36 questions (SF-36).

Results

Overall prevalence of neuropathic pain was 53.3 %. It was relatively high in patients with cervical spondylotic myelopathy (77.3 %) and ligament ossification (75.7 %) and relatively low in those with low back pain (29.4 %) and spondylolysis (40.4 %). Only 56.9 % of patients with radiculopathy were diagnosed with neuropathic pain. Logistic regression analysis identified several risk factors, including advanced age, severe pain, disease duration of at least 6 months, and cervical lesions. In QOL assessment, physical functioning, role-physical, role-emotional, and social functioning were severely affected, and this trend was more pronounced in patients who were more likely to have neuropathic pain.

Conclusions

The frequency of neuropathic pain tended to be higher in patients with diseases associated with spinal cord damage and lower in patients with diseases that primarily manifested as somatic pain. A bias toward allodynia symptoms in the screening questionnaire may have resulted in the failure to diagnose neuropathic pain in some patients with radiculopathy. Poor QOL, primarily from the aspect of physical functioning, was demonstrated in patients with neuropathic pain associated with spinal disorders.     

Ejaculatory disorders may affect screening for prostate cancer

PURPOSE: Ejaculatory disorders will be experienced in most men who are treated for localized prostate cancer. Baseline rates of ejaculatory disorders are unknown in men at risk for prostate cancer. Therefore, we explored the prevalence of those disorders and associated bother in men without evidence of prostate cancer who participated in an annual prostate cancer screening event. MATERIALS AND METHODS: A cohort of 1,273 men without clinical evidence of prostate cancer completed the self-administered Danish Prostate Symptom Score for sexual dysfunction. This questionnaire quantifies the rate of reduced ejaculatory volume, ejaculatory pain and the rate of coexistent erectile dysfunction. RESULTS: Mean age was 57.6 years (range 40 to 89). Of all men 46% (563) had reduced ejaculatory volume and 66% (356) of affected men were bothered by this condition. Ejaculatory pain was reported in 11% (134) and 89% (118) of these men reported associated bother. Finally, 45% (554) reported erectile dysfunction and 73% (403) reported associated bother. Reduced ejaculatory volume was associated with erectile dysfunction (p<0.001) and advanced age (p<0.001). Ejaculatory pain was not associated with one of these variables. CONCLUSIONS: Virtually all men will be affected by ejaculatory disorders after definitive treatment for localized prostate cancer. Therefore, it is important to observe that half of these individuals already have underlying reduced ejaculatory volume before treatment. Moreover, 1 of 10 men will be affected by ejaculatory pain. Both disorders are a significant source of bother and should be considered when treatment related quality of life is assessed.     

Symptom-based characteristics and treatment efficacy of neuropathic pain related to spinal disorders

BackgroundSymptom-based therapeutic management is required for neuropathic pain (NeP) to achieve higher treatment efficacy. In spinal disorders, which have a high prevalence of NeP, neurological symptoms are classified into myelopathy, radiculopathy, and cauda equina syndrome. The characteristics of pain and the treatment efficacy for each of these symptoms require clarification.MethodsA retrospective patient-based outcome study was conducted in 265 outpatients with chronic NeP (≥3 months) related to spinal disorders. The patients were classified into three groups according to their neurological symptoms: spinal cord-related pain, radicular pain, and cauda equina syndrome. Data were obtained from patient-based questionnaires using the Neuropathic Pain Symptom Inventory (NPSI) and the Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP), and from clinical information.ResultsMost of the patients with NeP had a NPSI score >10 (moderate to severe pain) and 40% had psychiatric problems. The common subtype of NeP was spontaneous pain and paresthesia/dysesthesia in patients with radicular pain and cauda equina syndrome, whereas more severe paresthesia/dysesthesia was particularly prominent in patients with spinal cord-related pain. The pain reduction rate was significantly lower in these latter patients, especially in association with residual paresthesia/dysesthesia.ConclusionsThe characteristics and treatment efficacy of NeP in patients with spinal disorders varied according to neurological symptoms. Effective treatment was difficult, especially for paresthesia/dysesthesia in patients with spinal cord-related pain. These findings enhance the understanding of the underlying mechanisms of pain and could help in design of symptom-based therapeutic management.     

Spondylogenic disorders in gymnasts

Spondylogenic injuries in gymnasts are not uncommon. As participation in organized gymnastics increases, health care professionals will be caring for more gymnasts who have spondylogenic disorders. The purpose of this paper is to review the literature regarding evaluation and treatment of various spondylogenic injuries. After defining various disorders, the mechanism of stress reaction in bone is presented. This aids the reader's understanding of how stress reactions can occur and progress in the gymnast. According to the literature, the gymnast usually presents with fairly reliable signs and symptoms, especially pain with hyperextension of the lumbar spine during single leg stance. Radiological studies are of significant diagnostic assistance, especially when a bone scan is used in conjunction with x-rays. Medical treatment methods vary widely, from complete immobilization to simple activity limitation. The rehabilitation and preventative aspects of care, as they relate to physical therapy, are reviewed. Emphasis is placed on spinal stabilization exercises to increase strength and muscular coordination. J Orthop Sports Phys Ther 1991;14(1):6-13.     

Interdisciplinary management of headache disorders

Chronic pain related to headache disorders causes significant burden of disease not only for the patients having these conditions, but also on society as a whole and often is associated with high utilization of health care systems. Despite advances in treatment, however, most patients with chronic headache continue to be undertreated or misdiagnosed. Appropriate evaluation using an in-depth history and physical examination, with imaging or laboratory studies as indicated by the findings of the examination, is paramount in selecting appropriate therapeutic options for treatment. Several studies on the effect of interdisciplinary care in patients with headache have shown improved outcomes for pain intensity, medication use, overall disability and work absence, and general mental health. Thus, it is recommended that care for patients with chronic headache disorders be interdisciplinary. Interdisciplinary care should include neurologic care and pharmacotherapy, physical therapies, complementary and alternative medicine, and psychological therapies. Consideration for interventional pain procedures or surgical procedures is recommended for patients with appropriate diagnoses or for those with pain refractory to conservative management.     

Spinal disorders in the elderly

As life expectancies increase, the geriatric population will increase, and the treatment of spinal diseases in the elderly will become even more commonplace. Treatment of spinal disorders in the geriatric patient population is a difficult challenge and involves numerous surgical, medical, and social issues. This review will provide an overview of the various spinal disorders particular to the geriatric patient population and will highlight certain concepts critical in the treatment of the spine in the geriatric population. Multiple factors, including poor tolerance of immobilization, medical comorbidities, use of multiple chronic medications, poor nutritional status, inadequate bone stock, and poor bone quality limit rigorous adherence to one treatment algorithm. These issues should be taken into consideration when formulating an individualized treatment plan that emphasizes early mobilization and functional rehabilitation. Goals, expectations, and surgical indications should be realistic and often will differ from those for a younger, healthier population. The use of a multidisciplinary approach will increase the likelihood of a successful treatment outcome and decrease the likelihood of potential complications.     

Somatization disorders of the urogenital tract

Diffuse symptoms in the urogenital region can frequently be explained by somatization disorders. Since they cannot be proven either by laboratory tests or with common technical diagnostic methods, somatization disorders should always be taken into consideration. Somatization disorders are to be considered functional disorders. Since somatization disorders due to muscular tension prevail in the urogenital region, the functional disturbance can be explained by the muscular tension. Subsequently, muscular tension causes the pathophysiological development of symptoms. As a rule they appear as myofascial pain or disorder. Muscular tension can have a psychic origin. The absence of urological findings is typical. Males and females between the ages of 16 and 75 can be affected by somatization disorders in the urogenital region. Somatization disorders due to muscular tension belong to the large group of symptoms due to tension. Diagnostic and therapeutic procedures as well as the pathophysiology of somatization disorders due to muscular tension are illustrated by two detailed case-reports.     

Development of a documentation instrument for the conservative treatment of spinal disorders in the International Spine Registry, Spine Tango

Spine Tango is the first and only International Spine Registry in operation to date. So far, only surgical spinal interventions have been recorded and no comparable structured and comprehensive documentation instrument for conservative treatments of spinal disorders is available. This study reports on the development of a documentation instrument for the conservative treatment of spinal disorders by using the Delphi consensus method. It was conducted with a group of international experts in the field. We also assessed the usability of this new assessment tool with a prospective feasibility study on 97 outpatients and inpatients with low back or neck pain undergoing conservative treatment. The new ‘Spine Tango conservative’ questionnaire proved useful and suitable for the documentation of pathologies, conservative treatments and outcomes of patients with low back or neck problems. A follow-up questionnaire seemed less important in the predominantly outpatient setting. In the feasibility study, between 43 and 63% of patients reached the minimal clinically important difference in pain relief and Core Outcome Measures Index at 3 months after therapy; 87% of patients with back pain and 85% with neck pain were satisfied with the received treatment. With ‘Spine Tango conservative’ a first step has been taken to develop and implement a complementary system for documentation and evaluation of non-surgical spinal interventions and outcomes within the framework of the International Spine Registry. It proved useful and feasible in a first pilot study, but it will take the experience of many more cases and therapists to develop a version similarly mature as the surgical instruments of Spine Tango.     

Psychotropic medication in chronic spinal disorders.

BACKGROUND CONTEXT: Optimal treatment of nonmalignant chronic spinal disorders (CSDs) may require the use of one or more nonopioid psychotropic medications. Vast research literature has documented high rates of psychiatric disorders in patients with CSDs. Psychotropic medications are one type of effective treatment for these disorders. Many medications of this type are also used as adjuvants to primary analgesic medications. PURPOSE: Physicians treating CSDs may have little training and experience in prescribing psychotropic medications. Further, they may possess limited information about the efficacy of these types of medications in treating psychiatric disorders comorbid with CSDs or as adjunctive analgesics. Because of the wide variety (antidepressants, anxiolytics, sleep-promoting agents, anticonvulsants, neuroleptics, muscle relaxants) and numerous indications for psychiatric medications, a concise review of the use of psychotropic medications with CSD patients is offered for the spine specialist. STUDY DESIGN: A systematic review of the contemporary English literature on psychotropic medications in the CSD population. METHODS: A computerized search of MEDLINE was performed on all English literature published from 1982 to August 2002. RESULTS: Psychotropic medications have been found to be very efficacious in the large subgroup of patients with CSDs with psychiatric comorbidity, particularly patients with the common constellation of depression, anxiety, excessive somatic complaints, insomnia and irritability. Although the type of medication indicated depends on the particular psychiatric syndrome(s), antidepressants have been found to be extremely useful with the constellation described above. There is less evidence to support the use of nonopioid psychotropic medications in the treatment of nociceptive pain, although clinical experience indicates that some individuals demonstrate a marked analgesic response. Research support for the efficacy of particular psychotropic medications in treating neuropathic pain is stronger, although more controlled research is clearly needed. CONCLUSIONS: Psychotropic medications are extremely useful in the treatment of psychiatric disorders comorbid with CSDs and modestly useful as analgesic adjuvants, particularly with pain of neuropathic etiology. Familiarity with these medications will aid the primary treating physician in optimizing outcomes in this difficult group of patients.     

Anterior spinal artery syndrome in two children with genetic thrombotic disorders

BACKGROUND: Spinal cord infarction is a well-described, but rare, etiology of myelopathy, especially in children. The most common syndrome, anterior spinal artery syndrome (ASAS), is caused by interruption of blood flow to the anterior spinal artery, producing ischemia in the anterior two-thirds of the cord, with resulting neurologic deficits. Causes of ASAS include aortic disease, thoracolumbar surgery, sepsis, hypotension, and thromboembolic disorders. METHODS: Case reports of 2 patients. RESULTS: Two children developed spinal cord infarctions consistent with ASAS, mostly likely caused by previously undiagnosed thrombotic disorders. A child with prothrombin variant experienced acute bilateral lower limb weakness without any preceding event. Magnetic resonance imaging (MRI) revealed increased T2 signal in the anterior cord from midthoracic level to the conus medullaris. A child with protein S deficiency developed lower limb weakness 1 day after a posterior thoracolumbar fusion for idiopathic scoliosis. Computed tomography (CT) myelogram revealed no spinal cord compression. The prothrombin variant mutation is associated with a 2-fold risk of thrombotic events. Individuals with protein S deficiency have an 8-fold increased risk of thrombosis. CONCLUSION: As knowledge of the coagulation pathways grows, it is likely that more patients with spinal cord infarctions will be diagnosed with genetic thrombotic disorders as the etiology of their injury. We review these two disorders, prothrombin variant and protein S deficiency, and the considerations for long-term anticoagulation.     

Spinal cord stimulation for relief of chronic pain in vasospastic disorders of the upper limbs

Eleven patients with chronic pain due to severe vasospastic disorders in the upper limbs were treated with cervical spinal cord stimulation. In 8 patients the pain was due to reflex sympathetic dystrophy in the late stage of the disease, and 3 patients had severe idiopathic Raynaud's disease. The mean follow-up for both groups was 27 months. A total of 10 patients (90.9%) had good or excellent results. Thermographic and plethysmographic changes were observed in both groups. There seems to be a very close relationship between the increase of blood flow and the amount of pain relief achieved. In an attempt to quantify the intensity of pain, the visual analog scale and McGill Pain Questionnaire were used. Stimulation proved to be harmless, with no mortality and very low morbidity. The latter centered around local infection and displacement of the electrodes. No objective changes occurred in trophic alterations such as bone decalcification and ankylosis, but there were improvements in the alterations in the nails and skin. In the reflex sympathetic dystrophy group, the amount of pain relief achieved enabled most patients to undergo subsequent physiotherapy and rehabilitation. In severe cases of reflex sympathetic dystrophy and idiopathic Raynaud's disease, spinal cord stimulation is an alternative treatment that can be used as primary therapy or as secondary therapy after unsuccessful sympathectomy or sympathetic blocks.     

Psychosomatic aspects in orthopedic legal assessment

AIM: Complaints in orthopaedics that are not sufficiently explainable can be caused (partly) by psychosomatic disorders. A manual psychosomatic disorders for legal assessment in orthopaedics will be supplied. METHOD: Diagnoses essential for orthopaedics are classified by DSM-IV and ICD-10 in consideration of the current literature; evaluation was performed under legal assessment criterions. RESULTS: The most important complaints that are often poorly explainable results in musculoskeletal pain. Since a sensorial perception of pain is combined with emotions, emotions and psychic disorders can be perceived as pain. The most important diagnoses for assessing not sufficiently explainable complaints by somatic cause are "somatoform pain disorder", "somatization disorder", "undifferentiated somatoform disorder", "conversion disorder", "hypochondriasis", "body dysmorphic disorder", "maior depression", "dysthymic disorder", "posttraumatic stress disorder", and "adjustment disorder". The relevance of psychosomatic comorbidity in legal assessment is possible in all affairs of civil and social law. Private accident insurances exclude psychic and psychosomatic diseases from all insurance benefits. CONCLUSION: When composing legal assessments in orthopaedics, especially on pain, the knowledge of psychosomatic (co)morbidity is necessary for meeting the different causes of the complaints. Under awareness of possible psychosomatic disorders, additional psychosomatic legal assessments can be recommended and understood as well.     

Gait disorders and leg deformities in children

Gait disorders and leg deformities have become the most prevalent orthopedic problems in children in Japan. Usually, at the first visit to our outpatient clinics, there are many difficulties in fully determining the causes and prognoses of these problems. Several series of observations, carried out at intervals, will be required to ascertain whether these problems are really pathologic or whether they are actually within the normal range. In-toeing gait and bow-legged deformities were the most common complaints observed in each of the above problems. The conditions in the majority of such patients were observed to spontaneously improve with time. However, we must always focus on the patient's past history, beginning from infancy, and we must carry out some physical examinations so as not to overlook any actual disorders underlying the patient's present condition. Received: June 25, 2001     

Intrathecal baclofen therapy for neurological disorders: a sound knowledge base but many challenges remain

Continuous infusion of intrathecal baclofen (ITB) via a subcutaneously implanted pump has developed over the last 20 years as a powerful tool in the management of spasticity in various adult and paediatric neurological conditions. Acting more focally on spinal GABA receptors, ITB causes fewer systemic side effects than orally administered baclofen. The result is facilitation of daily caring, and symptomatic relief from painful spasm. With increasing experience of ITB use, novel applications and indications are emerging. These include the management of dystonia and chronic neuropathic pain. However, despite some recent authoritative reviews, there is still uncertainty about optimal use and evaluation of this therapy. Many challenges remain. How can efficacy of therapy best be assessed both at primary testing and after pump implantation? What is the precise mechanism of baclofen action in different brain and spinal disorders associated with spasticity and dystonia? Does placement of the spinal catheter tip influence efficacy? What is the cranio-caudal gradient of CSF baclofen levels at given pump flow rates and does this matter? What CSF baclofen levels are efficacious in various conditions? Why do some patients with the same primary condition require large differences in ITB dose? What are the relative merits of programmable versus constant infusion rate pumps? What are the implications of setting up multidisciplinary teams for long term follow up? This review evaluates these questions and highlights other areas for further investigation.     

Back pain in children

Back pain is a common reason for presenting to the paediatric spinal clinic. Most will have non-specific back pain without an identifiable cause, but there are serious pathologies that should be considered and excluded prior to coming to this conclusion. This article focuses on the assessment, differential diagnosis and overview of management of frequently encountered causes of back pain in children.