Complex regional pain syndrome as a stress response

A man in his 50's with a prior traumatic brain injury and multiple psychiatric disorders developed acute pain and swelling in his left leg distal to the mid shin. These symptoms arose during an exacerbation of his post-traumatic stress disorder (PTSD). Among his traumatic memories, he reported having witnessed the combat injury and death of a friend who had lost his left leg distal to the mid shin. A diagnosis of conversion disorder was technically excluded because the findings met criteria for Complex Regional Pain Syndrome (CRPS) type I. Based on recent research into the neurobiology of CRPS, PTSD and conversion disorder, we propose a supraspinal mechanism which could explain how emotional stress can produce both symptoms and signs.     

Young patients with iliofemoral deep venous thrombosis should receive thrombolytic therapy

A 20-year-old otherwise healthy woman on oral contraceptive pills presents with sudden-onset left leg swelling and pain extending from her calf to her groin. Pulmonary embolism symptoms are lacking. Venous duplex ultrasound reveals acute deep venous thrombosis (DVT) involving the distal external iliac, common femoral, superficial femoral, and popliteal veins. Her leg is markedly swollen, slightly cool to the touch, but has preserved pedal pulses. She is unable to ambulate secondary to pain. Thrombolytic therapy to eliminate the DVT is recommended.     

Intraepidermal nerve fibers are indicators of small-fiber neuropathy in both diabetic and nondiabetic patients

OBJECTIVE: Small-fiber neuropathies may be symptomatic yet escape detection by standard tests. We hypothesized that morphologic changes in intraepidermal nerves would correlate with clinical measures of small-fiber neuropathy. RESEARCH DESIGN AND METHODS: We studied 25 diabetic and 23 nondiabetic patients with neuropathy defined by signs, symptoms, and quantitative testing and 20 control subjects. Skin biopsies were obtained from forearm, thigh, proximal leg, and distal leg, and nerves identified using immunofluorescence with antibody to protein gene product (PGP) 9.5. RESULTS: Mean dendritic length (MDL) (P < 0.01) and intraepidermal nerve fiber density (IENF) (P < 0.001) progressively decreased from proximal to distal sites only in patients with neuropathy. There was a significant reduction in IENF when comparing control subjects and patient groups in the distal leg (P < 0.001). MDL was significantly decreased in the thigh (P < 0.005) and in the proximal (P < 0.01) and distal (P < 0.002) leg in patients compared with control subjects. IENF was not significantly altered in diabetic patients of <5 years' duration, but significantly decreased in patients with >5 years' duration. MDL showed a linear decrease with increasing duration of diabetes. Distal leg IENF showed significant negative correlations with warm (P < 0.02) and cold (P < 0.05) thermal threshold, heat pain (P < 0.05), pressure sense (P < 0.05), and neurological disability score total sensory (P < 0.03) and total neuropathy (P < 0.03) values. CONCLUSIONS: IENF was not significantly altered in these patients at <5 years' duration of diabetes, but fell significantly after 5 years of diabetes. MDL exhibited a linear loss with time, suggesting a different mechanism of change. MDL and IENF together may prove a useful end point in therapeutic trials for neuropathy.     

Classification of low back-related leg pain--a proposed patho-mechanism-based approach

Leg pain is a frequent accompaniment to low back pain, arising from disorders of neural or musculoskeletal structures of the lumbar spine. Differentiating between different sources of radiating leg pain is important to make an appropriate diagnosis and identify the underlying pathology. It is proposed that low back-related leg pain be divided into four subgroups according to the predominating pathomechanisms involved. The first subgroup features central sensitization with mainly positive symptoms such as hyperalgesia, the second subgroup involves denervation with significant axonal damage showing predominantly negative sensory symptoms and possibly motor loss and the third subgroup involves peripheral nerve sensitization with enhanced nerve trunk mechanosensitization. The fourth subgroup features somatic referred pain from musculoskeletal structures, such as the intervertebral disc or facet joints. Accordingly, four groups of patients with leg pain associated with structures in the lower back can be identified: Each group presents with a distinct pattern of symptoms and signs. Although there may be considerable overlap between the classifications, the authors propose the existence of an overriding mechanism. The importance of distinguishing low back-related leg pain into these four groups is to facilitate diagnosis and provide a more effective, appropriate treatment.     

Unmyelinated and myelinated skin nerve damage in Guillain-Barré syndrome: correlation with pain and recovery

We performed a prospective study in 32 patients with Guillain-Barré syndrome (GBS) or its variants to correlate intraepidermal nerve fiber density (IENFD) at the distal leg and lumbar region with pain, autonomic dysfunction, and outcome. In the acute phase, IENFD was reduced in 60% and 61.9% of patients at the distal leg and lumbar region, respectively. In the acute phase, 43.7% of patients complained of neuropathic pain. Their IENFD at the distal leg was significantly lower than in patients without pain (P < .001) and correlated with pain intensity (r_s = −0.51; P = .003). Intriguingly, also patients with the pure motor variant of GBS and pain had low IENFD. At 6-month follow-up, only 3 patients complained of persisting neuropathic pain, whereas 3 patients reported late-onset pain symptoms. IENFD in the acute phase did not predict presence or intensity of pain at 6-month follow-up. IENFD in the acute phase did not correlate with clinical dysautonomia or GBS severity at nadir. However, it correlated with poorer GBS disability score at 6 months (P = .04), GBS score at nadir (P = .03), and clinically probable dysautonomia (P = .004). At 6-month follow-up, median IENFD remained significantly low both at the distal leg (P = .024) and lumbar region (P = .005). Double and triple staining confocal microscope studies showed diffuse damage of myelinated dermal nerves along with axonal degeneration, and mononuclear cell infiltration. Unmyelinated and myelinated skin nerves are diffusely affected in GBS and its variants, including the pure motor form. IENFD declines early, remains low over time, correlates with pain severity in the acute phase, and may predict long-term disability.     

Buerger运动用于下肢创伤患者康复训练的研究

目的观察Buerger运动用于下肢创伤患者康复训练的效果。方法将96例下肢创伤患者随机分为实验组和对照组,实验组48例采用Buerger运动进行康复训练,对照组48例采用传统功能锻炼法进行康复训练,观察两组患者下床活动后患肢肿胀、疼痛和紫绀情况,比较两种方法的康复效果。结果两组患者下床活动第一天患肢的肿胀、疼痛和紫绀程度采用秩和检验(P<0.01);第7天患肢的肿胀、疼痛和紫绀消退情况采用卡方检验(P<0.01)。结论Buerger运动康复训练能有效预防或减轻下肢创伤患者下床活动后患肢出现的肿胀、疼痛和紫绀症状,缩短康复时间,该方法值得临床推广应用。     

Relation between pain location and disc pathology: a study of pain drawings and CT/discography.

OBJECTIVE: The purpose of this study was to determine whether pain location indicated in pain drawings was related to the specific lumbar disc level(s) that was abnormal in appearance and painful upon discographic injection. DESIGN: Data were collected prospectively. SETTING: This study was conducted in a spine specialty clinic. PATIENTS: The study group consisted of 187 patients (118 men, 69 women; mean age = 37.2 years, range = 18-62 years) with low back pain with or without leg pain. All patients were undergoing computed tomography (CT)/discography at the three lowest lumbar levels for diagnostic purposes. Interventions: Pain drawings were completed the day of but prior to undergoing discography. Discographic pain responses were recorded with respect to the similarity to the patient's clinical symptoms. Pain drawings were classified based on the presence or absence of pain in five areas: low back and/or buttocks, posterior thigh, posterior leg, anterior thigh, and anterior leg. The drawings were scored with the system described by Ransford et al. (1976, Spine 1: 127-34), and those likely to be indicative of psychological problems were analyzed separately (n = 43). OUTCOME MEASURES: Results were determined by analyzing the relation between the location of pain in the drawings and the specific lumbar disc level(s) found to be painful and disrupted by discography. RESULTS: There was a significant relation between pain location indicated in the drawing and the lumbar disc level(s) identified as clinically painful and disrupted by CT/discography (p < 0.05, chi-square). Pain limited to the low back and buttocks was frequently associated with the absence of disc pathology (58.3%). When pain in the posterior thigh or leg was present but there was no pain in the anterior drawing, patients frequently had a positive L5-S 1 disc (> or =75%). In patients with anterior thigh pain, with or without posterior thigh or leg pain, the L4-5 disc was frequently symptomatic (>63%). The pattern of no posterior thigh or leg pain but with pain radiating into the leg anteriorly was most commonly associated with the L3-4 disc (71.4%). CONCLUSIONS: The results of this study indicate that pain drawings may be helpful in identifying which specific discs are associated with pain complaints. As with any evaluation, the drawings should be considered in combination with findings from other assessments.     

Identification of Symptom Clusters in Patients With Chronic Venous Leg Ulcers

ContextPatients with venous leg ulcers experience multiple symptoms, including pain, depression, and discomfort from lower leg inflammation and wound exudate. Some of these symptoms impair wound healing and decrease quality of life (QOL). The presence of co-occurring symptoms may have a negative effect on these outcomes. The identification of symptom clusters could potentially lead to improvements in symptom management and QOL.ObjectivesTo identify the prevalence and severity of common symptoms and the occurrence of symptom clusters in patients with venous leg ulcers.MethodsFor this secondary analysis, data on sociodemographic characteristics, medical history, venous history, ulcer and lower limb clinical characteristics, symptoms, treatments, healing, and QOL were analyzed from a sample of 318 patients with venous leg ulcers who were recruited from hospital outpatient and community nursing clinics for leg ulcers. Exploratory factor analysis was used to identify symptom clusters.ResultsAlmost two-thirds (64%) of the patients experienced four or more concurrent symptoms. The most frequent symptoms were sleep disturbance (80%), pain (74%), and lower limb swelling (67%). Sixty percent of patients reported three or more symptoms at a moderate-to-severe level of intensity (e.g., 78% reported disturbed sleep frequently or always; the mean pain severity score was 49 of 100, SD 26.5). Exploratory factor analysis identified two symptom clusters: pain, depression, sleep disturbance, and fatigue; and swelling, inflammation, exudate, and fatigue.ConclusionTwo symptom clusters were identified in this sample of patients with venous leg ulcers. Further research is needed to verify these symptom clusters and to evaluate their effect on patient outcomes.     

An unusual extraspinal cause of bilateral leg pain.

Low back pain with pain radiating to the lower extremities is common in patients referred to a spine center. Lumbar spine pathology is commonly the etiology of such symptoms, but extraspinal causes of back and leg pain can manifest as a radicular disorder. Extraspinal etiologies must be considered in the workup of back and leg pain. This report describes an unusual case of spontaneously occurring bilateral femoral neck stress fractures presenting as low back pain with seemingly bilateral L4 radicular symptoms.     

Application of a classification system and description of a combined manual therapy intervention: a case with low back related leg pain

Low back pain and leg pain commonly occur together. Multiple factors can cause low back related leg pain; therefore, identification of the source of symptoms is required in order to develop an appropriate intervention program. The patient in this case presented with low back and leg pain. A patho-mechanism based classification is described in combination with the patient’s subjective and objective examination findings to guide treatment. The patient’s symptoms improved marginally with intervention addressing primarily the musculoskeletal impairments and with intervention addressing primarily the neurodynamic impairments. Full functional improvements were attained with a manual therapy intervention directed at both mechanisms simultaneously. The approach described in this case address a mixed pathology utilizing passive accessory and passive physiological lumbar mobilizations in combination with lower extremity neurodynamic mobilization. The patient reported complete resolution of symptoms after a total of seven visits over a period of 6 weeks. While specific guidelines do not yet exist for treatment based on the classification approach utilized, this case report provides an example of manual therapy to address low back related leg pain of mixed pathology.     

How is radiating leg pain defined in randomized controlled trials of conservative treatments in primary care? A systematic review

Many terms exist to describe radiating leg pain or symptoms associated with back pain (e.g., sciatica or radiculopathy) and it appears that these terms are used inconsistently. We examined the terms used to describe, and the eligibility criteria used to define, radiating leg pain in randomized controlled trials of conservative treatments, and evaluated how the eligibility criteria compared to an international pain taxonomy. Eligible studies were identified from two systematic reviews and an updated search of their search strategy. Studies were included if they recruited adults with radiating leg pain associated with back pain. Two independent reviewers screened the studies and extracted data. Studies were grouped according to the terms used to describe radiating leg pain. Thirty‐one of the seventy‐seven included studies used multiple terms to describe radiating leg pain; the most commonly used terms were sciatica (60 studies) and disc herniation (19 studies). Most studies that used the term sciatica included pain distribution in the eligibility criteria, but studies were inconsistent in including signs (e.g., neurological deficits) and imaging findings. Similarly, studies that used other terms to describe radiating leg pain used inconsistent eligibility criteria between studies and to the pain taxonomy, except that positive imaging findings were required for almost all studies that used disc herniation to describe radiating leg pain. In view of the varying terms to describe, and eligibility criteria to define, radiating leg pain, consensus needs to be reached for each of communication and comparison between studies.     

Treatment of a patient with post-natal chronic calf pain utilizing instrument-assisted soft tissue mobilization: a case study

Abstract

Musculoskeletal pain is commonly reported by pre- and postnatal women, with the most common complaint being low back pain. However, lower leg pain is also frequently reported by women particularly in the third trimester. The purpose of the case study is to illustrate how instrument-assisted soft tissue mobilization (ISTM) can be used to treat a patient with a 2-year history of chronic calf pain. The subject was a 35-year-old female who developed calf pain during the last trimester of her pregnancy following severe lower leg edema. The calf pain was present for the 2 years following delivery and was described as a dull ache, typically aggravated by direct pressure on the calf, prolonged standing, and stairs. An X-ray, magnetic resonance imaging (MRI) with contrast, and ultrasound Doppler study prior to referral ruled out tumors, vascular, lymphatic, or skeletal bone abnormalities. However, her MRI did show a dense superficial venous tissue asymmetry in the same location of her symptoms. Impairments were minimal; the only asymmetrical objective findings were calf length, strength, and soft tissue restrictions detected on palpation. After nine treatments incorporating an ISTM approach, soft tissue mobility, pain, calf strength, and lower extremity functional scale score all improved and her symptoms were abolished.     

Mechanisms-based classifications of musculoskeletal pain: part 3 of 3: symptoms and signs of nociceptive pain in patients with low back (± leg) pain

As a mechanisms-based classification of pain 'nociceptive pain' (NP) refers to pain attributable to the activation of the peripheral receptive terminals of primary afferent neurones in response to noxious chemical, mechanical or thermal stimuli. The symptoms and signs associated with clinical classifications of NP have not been extensively studied. The purpose of this study was to identify symptoms and signs associated with a clinical classification of NP in patients with low back (± leg) pain. Using a cross-sectional, between-subjects design; four hundred and sixty-four patients with low back (± leg) pain were assessed using a standardised assessment protocol after which their pain was assigned a mechanisms-based classification based on experienced clinical judgement. Clinicians then completed a clinical criteria checklist indicating the presence/absence of various symptoms and signs. A regression analysis identified a cluster of seven clinical criteria predictive of NP, including: 'Pain localised to the area of injury/dysfunction', 'Clear, proportionate mechanical/anatomical nature to aggravating and easing factors', 'Usually intermittent and sharp with movement/mechanical provocation; may be a more constant dull ache or throb at rest', and the absence of 'Pain in association with other dysesthesias', 'Night pain/disturbed sleep', 'Antalgic postures/movement patterns' and 'Pain variously described as burning, shooting, sharp or electric-shock-like'. This cluster was found to have high levels of classification accuracy (sensitivity 90.9%, 95% CI: 86.6-94.1; specificity 91.0%, 95% CI: 86.1-94.6). Pattern recognition of this empirically-derived cluster of symptoms and signs may help clinicians identify an assumed dominance of NP mechanisms in patients with low back pain disorders.     

首发症状为腰腿痛的脊髓血管病血管内治疗与术后康复干预

目的:探讨首发症状为腰腿痛的脊髓血管病的血管内治疗与术后康复干预的疗效。方法:脊髓内血管畸形6例,脊髓周动静脉瘘1例及硬脊膜动静脉瘘1例,采用聚乙烯醇(PolyvinylAlcohol,PVA)颗粒、α-氰基丙烯酸正丁酯(N-Butylcyanoacrylate,NBCA)、螺旋圈(Coil)栓塞治疗的同时,采取神经功能康复治疗。结果:8例均进行经血管内栓塞治疗,5例供血动脉完全栓塞,占62.5%(5/8);供血动脉大部分栓塞,占37.5%(3/8),仅余细小的动脉供血。术后经过进一步康复干预治疗后,6例腰腿痛症状消失,占75%(6/8),2例明显改善,占25%(2/8),神经功能恢复满意。结论:采用经血管内栓塞是治疗脊髓血管病的一种微创、安全、有效的方法,栓塞术后的康复治疗是促进脊髓神经功能恢复的必要手段。     

Treatment of degenerative lumbar spinal stenosis

Spinal stenosis is a narrowing of the vertebral canal that compresses spinal nerves and may cause leg pain and difficulty walking. The symptoms of degenerative lumbar stenosis commonly occur in elderly adults and can be treated conservatively with pain-relieving agents or aggressively with decompressive surgery. Most studies of the effectiveness of treatments are poor in quality; however, there appear to be potential relationships between treatments, patient characteristics, and treatment outcomes. Studies indicate the following: (1) local anesthetic block can reduce symptoms on a short-term basis, while epidural steroids offer no additional benefit; (2) patients with moderate or severe symptoms benefit more from surgery than from conservative therapy; and (3) patients with leg pain and severely restricted walking ability regain mobility after surgery. Definitive evidence-based conclusions about the efficacy of conservative or surgical treatments await the results of well-designed clinical trials.     

Back Pain with Leg Pain

Purpose of Review

The clinical diagnostic dilemma of low back pain that is associated with lower limb pain is very common. In relation to back pain that radiates to the leg, the International Association for the Study of Pain (IASP) states: “Pain in the lower limb should be described specifically as either referred pain or radicular pain. In cases of doubt no implication should be made and the pain should be described as pain in the lower limb.”

Recent Findings

Bogduks’ editorial in the journal PAIN (2009) helps us to differentiate and define the terms somatic referred pain, radicular pain, and radiculopathy. In addition, there are other pathologies distal to the nerve root that could be relevant to patients with back pain and leg pain such as plexus and peripheral nerve involvement. Hence, the diagnosis of back pain with leg pain can still be challenging.

Summary

In this article, we present a patient with back and leg pain. The patient appears to have a radicular pain syndrome, but has no neurological impairment and shows signs of myofascial involvement. Is there a single diagnosis or indeed two overlapping syndromes? The scope of our article encompasses the common diagnostic possibilities for this type of patient. A discussion of treatment is beyond the scope of this article and depends on the final diagnosis/diagnoses made.

     

Evidence of focal small-fiber axonal degeneration in complex regional pain syndrome-I (reflex sympathetic dystrophy)

CRPS-I consists of post-traumatic limb pain and autonomic abnormalities that continue despite apparent healing of inciting injuries. The cause of symptoms is unknown and objective findings are few, making diagnosis and treatment controversial, and research difficult. We tested the hypotheses that CRPS-I is caused by persistent minimal distal nerve injury (MDNI), specifically distal degeneration of small-diameter axons. These subserve pain and autonomic function. We studied 18 adults with IASP-defined CRPS-I affecting their arms or legs. We studied three sites on subjects’ CRPS-affected and matching contralateral limb; the CRPS-affected site, and nearby unaffected ipsilateral and matching contralateral control sites. We performed quantitative mechanical and thermal sensory testing (QST) followed by quantitation of epidermal neurite densities within PGP9.5-immunolabeled skin biopsies. Seven adults with chronic leg pain, edema, disuse, and prior surgeries from trauma or osteoarthritis provided symptom-matched controls. CRPS-I subjects had representative histories and symptoms. Medical procedures were unexpectedly frequently associated with CRPS onset. QST revealed mechanical allodynia (P < 0.03) and heat-pain hyperalgesia (P < 0.04) at the CRPS-affected site. Axonal densities were highly correlated between subjects’ ipsilateral and contralateral control sites (r = 0.97), but were diminished at the CRPS-affected sites of 17/18 subjects, on average by 29% (P < 0.001). Overall, control subjects had no painful-site neurite reductions (P = 1.00), suggesting that pain, disuse, or prior surgeries alone do not explain CRPS-associated neurite losses. These results support the hypothesis that CRPS-I is specifically associated with post-traumatic focal MDNI affecting nociceptive small-fibers. This type of nerve injury will remain undetected in most clinical settings.     

Tactile allodynia in patients with lumbar radicular pain (sciatica)

We report a novel symptom in many patients with low back pain (LBP) that sheds new light on the underlying pain mechanism. By means of quantitative sensory testing, we compared patients with radicular LBP (sciatica), axial LBP (LBP without radiation into the leg), and healthy controls, searching for cutaneous allodynia in response to weak tactile and cooling stimuli on the leg and low back. Most patients with radicular pain (~60%) reported static and dynamic tactile allodynia, as well as cooling allodynia, on the leg, often extending into the foot. Some also reported allodynia on the low back. In axial LBP, allodynia was almost exclusively on the back. The degree of dynamic tactile allodynia correlated with the degree of background pain. The presence of allodynia suggests that the peripheral nerve generators of background leg and back pain have also induced central sensitization. The distal (foot) location of the allodynia in patients who have it indicates that the nociceptive drive that maintains the central sensitization arises paraspinally (ectopically) in injured ventral ramus afferents; this is not an instance of somatic referred pain. The presence of central sensitization also provides the first cogent account of shooting pain in sciatica as a wave of activity sweeping vectorially across the width of the sensitized dorsal horn. Finally, the results endorse leg allodynia as a pain biomarker in animal research on LBP, which is commonly used but has not been previously validated. In addition to informing the underlying mechanism of LBP, bedside mapping of allodynia might have practical implications for prognosis and treatment.Social media questionHow can you tell whether pain radiating into the leg in a patient with sciatica is neuropathic, ie, due to nerve injury?