La lombalgie en consultation hospitalière à Lomé (Togo)Low back pain in hospital outpatients in Lomé (Togo).

Objective. To determine the patterns of low back pain and the conditions associated with this symptom in outpatients attending the rheumatology unit of the Lomé teaching hospital. Methods. Medical records of patients seen over a ten-year period were studied retrospectively. Results. Among the 9065 patients seen, 3204 (35.34%; 1850 women and 1354 men) had low back pain. Mean age at onset was 41 years, and mean duration of low back pain was 3 years. Diseases associated with low back pain were as follows: degenerative spinal disease, N= 3054 (95.32 %); spinal infections, N=79 (2.47 %) ; spondyloarthropathies, N=44 (1.37 %) ; and tumors, N=27 (0.84 %). The features of degenerative spinal disease included back pain (n=1535, 47.91 %), lumbar and radicular pain suggestive of disc herniation (n=1108, 34.58 %), and lumbar and radicular pain with claudication suggestive of lumbar spinal stenosis (n=411, 12.83 %). Schöber’s test was abnormal in 831 of the 1408 patients (59 %) with acute pain or disc herniation. Most patients with lumbar spinal stenosis were women (72.26 %) and were aged 35 to 64 years. Findings suggestive of tuberculosis were present in 62 of the 79 patients with lumbar spinal infection. Among the 44 patients with spondyloarthropathies, 15 had ankylosing spondylitis and 11 had infection with the human immunodeficiency virus (HIV). Multiple myeloma was present in 10 patients and metastatic tumors in eight. Conclusion. Low back pain seems to be as common in sub-Saharan Africa as in occidental countries, with a prevalence of one-third among rheumatology outpatients. Lumbar spinal stenosis seems more common than in the Occident and is mainly observed in woman.  Schöber’s test is not useful for measuring lumbar flexion in Africans. The epidemiology of spondyloarthropathies in sub-Saharan Africa has been changed by the expanding HIV epidemic, despite the low prevalence of HLA B27.     

The best back to manipulate?

A series of 104 patients 'cured' by one, or at most two, manipulations in reviewed. A clinical syndrome emerges--recent and/or sudden onset of back pain and leg pain, no neurological symptoms or signs, a mechanical pattern of back movements with extension more limited than flexion, straight leg raising (SLR) more than 60 degrees and no neurological signs.     

Type B aortic dissection associated with <Emphasis Type="Italic">Salmonella</Emphasis> infection

A 59-year-old man with a long history of hypertension and diabetes was admitted to our hospital with acute type B aortic dissection 14 days after the sudden onset of back pain. The dissecting descending thoracic aorta was enlarged to 5.2 cm in diameter, and laboratory tests showed an elevated white blood cell count (15 530/mm³) and an increased C-reactive protein level (19.2 mg/dl). Computed tomography performed 2 days after admission revealed rapid growth of the aortic dissection. Blood cultures obtained upon admission were positive for Salmonella. Impending rupture of the aortic dissection complicated by Salmonella infection was strongly suspected, and the patient underwent emergency surgery consisting of debridement and prosthetic graft placement covered by an omental flap. In this case, it is believed that insidious Salmonella aortitis caused acute type B aortic dissection.     

Factors affecting neurological deficits and intractable back pain in patients with insufficient bone union following osteoporotic vertebral fracture

The purpose of this study was to examine factors affecting the severity of neurological deficits and intractable back pain in patients with insufficient bone union following osteoporotic vertebral fracture (OVF). Reports of insufficient union following OVF have recently increased. Patients with this lesion have various degrees of neurological deficits and back pain. However, the factors contributing to the severity of these are still unknown. A total of 45 patients with insufficient union following OVF were included in this study. Insufficient union was diagnosed based on the findings of vertebral cleft on plain radiography or CT, as well as fluid collection indicating high-intensity change on T2-weighted MRI. Multivariate logistic regression analysis was performed to determine the factors contributing to the severity of neurological deficits and back pain in the patients. Age, sex, level of fracture, duration after onset of symptoms, degree of local kyphosis, degree of angular instability, ratio of occupation by bony fragments, presence or absence of protrusion of flavum, and presence or absence of ossification of the anterior longitudinal ligament (OALL) in the adjacent level were used as explanatory variables, while severity of neurological deficits and back pain were response variables. On multivariate analysis, factors significantly affecting the severity of neurological deficits were angular instability of more than 15° [adjusted odds ratio (OR), 9.24 (95% confidence interval, CI 1.49–57.2); P < 0.05] and ratio of occupation by bony fragments in the spinal canal of more than 42% [adjusted OR 9.23 (95%CI 1.15–74.1); P < 0.05]. The factor significantly affecting the severity of back pain was angular instability of more than 15° [adjusted OR 14.9 (95%CI 2.11–105); P < 0.01]. On the other hand, presence of OALL in the adjacent level reduced degree of back pain [adjusted OR 0.14 (95%CI 0.03–0.76); P < 0.05]. In this study, pronounced angular instability and marked posterior protrusion of bony fragments in the canal were factors affecting neurological deficits. In addition, marked angular instability was a factor affecting back pain. These findings are useful in determining treatment options for patients with insufficient union following OVF.     

Life events and psychological disturbance in patients with low-back pain

To elucidate the possible contribution of psychologic factors in the pathogenesis of back pain, an assessment of life events and psychiatric symptoms was undertaken in 80 new referrals. In 57, the back pain had a definite onset recent enough to allow this to be dated accurately; these definite onset cases were divided into 26 in whom a specific organic diagnosis could be made and 31 in whom the cause of the pain was uncertain. An additional 23 patients had chronic pain, or could not date the onset of their symptoms. Unlike previous studies, events that occurred after the onset of back pain and thus could have been a consequence of the back pain were excluded. Before onset of back pain there was a significant excess of adverse life events in those with definite onset back pain of uncertain cause, compared with those with a specific diagnosis: there was no such excess in the periods before referral and attendance at the clinic. Diagnosable psychiatric illness was virtually confined to those with chronic pain. These findings indicate that stress, but not psychiatric illness, is involved in the onset of back pain. Further research is now required to ascertain whether those patients who have many psychiatric symptoms at the time of onset are those who develop chronic pain.     

Reduced risk of back pain following teriparatide treatment: a meta-analysis

Vertebral fractures are the most common osteoporotic fracture and may result in back pain with functional limitations and diminished quality of life. Teriparatide [rhPTH (1–34)] has been shown to increase bone mass and reduce the risk of vertebral and other osteoporotic fractures. The aim of this study was to evaluate the effects of teriparatide on the risk of back pain in patients with osteoporosis. A systematic review of the literature was performed, and five trials were identified and included in our analyses. All trials were randomized, double-blinded, and parallel with either new vertebral fracture ( n =1) or bone mineral density as the primary endpoint ( n =4). Four studies were in postmenopausal women with osteoporosis, and one was in men with idiopathic or hypogonadal osteoporosis. Two trials were placebo controlled, two trials were alendronate controlled, and one trial involved teriparatide plus hormone replacement therapy versus hormone replacement therapy alone. Reports of back pain, defined as new or worsened back pain after initiating the study drug, were obtained from adverse event databases, and the risk of back pain was analyzed using a multivariate Cox proportional hazards model. Results were not statistically heterogeneous ( P =0.60) across trials, and there were no differences between groups administered teriparatide 20 or 40 mcg/day doses ( P =0.64). The rates of back pain, moderate or severe back pain, and severe back pain per 100 patient-years were numerically lower in the teriparatide versus comparator groups in each study. Compared with the pooled comparator, patients in the pooled teriparatide group had reduced risk for any back pain [relative risk, 0.66 (95% CI, 0.55–0.80)], moderate or severe back pain [relative risk, 0.60 (95% CI, 0.48–0.75)] and severe back pain [relative risk, 0.44 (95% CI, 0.28–0.68)]. Separate meta-analyses comparing teriparatide versus placebo or antiresorptive drugs gave similar results. In conclusion, patients randomized to teriparatide had a reduced risk of new or worsening back pain compared to patients randomized to placebo, hormone replacement therapy or alendronate.     

Vertebral osteomyelitis after cardiac surgery

Background

Mediastinitis after open-heart surgery is a serious complication that has a decreasing incidence but still a significantly high mortality rate. Back pain may develop during the course of treatment for mediastinitis, and this should suggest vertebral osteomyelitis in the differential diagnosis. Diagnosis of vertebral osteomyelitis may be difficult because of the insidious onset and delayed diagnosis, and treatment may result in serious neurologic compromise and even death of the patient.

Methods

This retrospective study involves 5 patients who had open-heart surgery and mediastinitis that was further complicated by vertebral osteomyelitis. Average delay in diagnosis was 18 days after the onset of symptoms. Magnetic resonance imaging was the most helpful tool for diagnosis. Methicilline-resistant Staphylococcus aureus was identified as the responsible microorganism in all patients. Neurologic compromise occured (one paraplegia and one paraparesia) in 2 patients during medical treatment.

Results

Along with the medical treatment, all patients were surgically treated due to either one or more of the following reasons: unresolving symptoms, sudden neurologic compromise, or impaired spinal column stability despite appropriate conservative treatment. One patient died 10 days postoperatively. The mean follow-up period for the remaining 4 patients was 47 (12 to 95) months. Complete recovery was achieved, and they were able to return to their routine daily activities.

Conclusions

Vertebral osteomyelitis should be borne in mind when a patient develops back pain during the course of mediastinitis. Suspicion, early diagnosis with appropriate imaging, and proper treatment are crucial to prevent catastrophic complications.     

Low back pain: results of an open clinical trial comparing the standard treatment alone to the combination of standard treatment and thiocolchicoside

For symptomatic relief of low back pain, non-steroidal antiinflammatory drugs (NSAIDs) and analgesics are often in used in combination with muscle relaxants. However adverse effects, especially sedation, limit the use of some muscle relaxants. Thiocolchicoside (TCC) is a non-sedating muscle relaxant that has been shown to be safe and effective as monotherapy in the treatment of this problem. The present study was carried out to determine if the combination of thiocolchicoside and standard treatment is more effective than standard treatment alone. Ninety-three Turkish centers recruited adults presenting with acute and subacute low back pain. Each physician included four patients. Patients were randomized to receive either a NSAID or an analgesic for 5 to 7 days (referred to as “standard treatment”) or standard treatment plus 8 mg TCC (Muscoril) twice daily for 5 to 7 days. On inclusion and again on day 7, low back pain was evaluated with a visual analogue scale (VAS) and disability was evaluated with the Roland-Morris disability questionnaire. Pain and disability were evaluated again on day 31. A total of 155 patients were randomized to receive standard treatment alone and 174 received standardtreatment and TCC. The vast majority (98.2%) of the patients received a NSAID as standard treatment. The mean VAS and disability questionnaire scores of the two groups were equivalent at inclusion. At day 7, patients in both groups were improved but patients receiving TCC had significantly less pain (p<0.003) and disability (p=0.0005) than patients on standard treatment alone; this was also true at day 31. (p<0.005 and p=0.0005, respectively). The addition of TCC to NSAID standard treatment resulted more effective for the symptomatic treatment of low back pain than the NSAID alone. In addition, the combination was well tolerated and produced no more adverse effects than the NSAID alone. Received: 27 November 2001, Accepted: 4 April 2002     

Misleading history of pain location in 51 patients with osteoporotic vertebral fractures

The aim of this study was to investigate associations between the location of osteoporotic vertebral fractures and the patient’s localization of pain. Fifty-one consecutive patients (m 6, f 45; average age 74.8 years) with diagnosed osteoporotic vertebral fractures between T8 and L2 were included in the study. Exclusion criteria were fractures above T8 and below L2, spondylolisthesis, disc herniations, tumors, infections, and instability. Pain location was assessed by pain drawing, subdivided into thoracic, lumbar, and thoracic plus lumbar pain areas, and pain intensity using a 101 numeric rating scale. Furthermore, the onset of back pain and the lack or the indication of a trigger event at the onset of pain were documented. Only four of 20 patients with thoracic fractures reported thoracic pain, while the other 16 (80%) reported only lumbar pain. The location of the fracture and the patient’s pain report were not related (Cohens Kappa=0.046; P=0.438). Patients with thoracic or lumbar osteoporotic fractures report pain mainly in the lumbosacrogluteal area. Therefore, the complaint of low back pain (LBP) in persons at risk for osteoporotic fractures may require both thoracic and lumbar X-rays. LBP patients with a suspect history of an osteoporotic vertebral fracture should also be given an X-ray of the thoracic and lumbar spine. Patients with a thoracic vertebral fracture had more severe pain than patients with a lumbar vertebral fracture. Onset not related to a fall or a false movement related to a significantly longer pain duration.     

Sacroiliac joint pain after lumbar fusion. A study with anesthetic blocks

Low back pain persisting or appearing after a technically successful lumbar fusion challenges clinicians. In this context, the sacroiliac joint could be a possible source of pain, but the frequency of its responsibility is not really known. We used sacroiliac anesthetic blocks, the gold standard for diagnosis, to determine this frequency. Our second goal was to search predictive factors for a positive block. Our prospective series consisted of 40 patients with persistent low back pain after a technically successful fusion who received a sacroiliac anesthetic block under fluoroscopic control. The diagnostic criterion was a relief of more than 75% of the pain on a visual analog scale. We found a 35% rate of positive blocks. The only criterion that characterized these patients was a postoperative pain different from the preoperative pain in its distribution ( p =0.017). A free interval of more than 3 months between surgery and appearance of the pain had an indicative value ( p =0.17). An increased uptake in the sacroiliac on bone scintigraphy or a past history of posterior iliac bone-graft harvesting had no significant value ( p =0.74 and p =1.0, respectively). The sacroiliac joint is a possible source of pain after lumbar fusion. The anesthetic block under fluoroscopic control remains the gold standard.     

Pyogenic Spondylitis

During the period 1972-1974 10 patients suffering from pyogenic spondylitis have been treated at the Central Hospital of Middle Finland. Three of the patients had become acutely ill with septic fever and back pain. In the remaining cases the onset of the disease was insidious. Fever, weight loss and fatigue were the general symptoms. Percussion revealed local tenderness at the site of infection in all patients. Two patients showed neurological signs. The ESR was elevated in all cases and alkaline phosphatase was elevated in six patients. Blood culture was positive in those three patients who had become acutely ill. Narrowing of the intervertebral space was observed in all patients. Scanning with Tc⁹⁹ was performed in nine patients, seven of whom were at an early stage of the disease; a significant uptake was recorded in five of these cases. The average interval between the onset of symptoms and the diagnosis was 3 months, range 1 to 5 months. The treatment consisted of bed rest and antibiotics. All the patients recovered and became symptom-free.     

The Health Consequences of Vertebral Deformity in Elderly Chinese Men and Women

The following health consequences of vertebral deformity in Hong Kong elderly Chinese men and women were studied: the prevalence of back pain, disability due to back pain, and low morale. Lateral X-ray films were taken of the thoracic and lumbar spine of 796 community-dwelling Chinese subjects (396 men, 400 women) (aged 70–79). Subjects with one or more definitely deformed vertebra (reduction in vertebral height 3 SD or more below the mean) were classified as definite cases, those with one or more mildly deformed vertebra (reduction in vertebral height 2–2.99 SD below the mean) as mild cases, and the rest as controls. The prevalence and consequences of back pain were measured by a standardized questionnaire, and morale was measured by the Geriatric Morale Score. The relative risk (RR) and 95% confidence interval (CI) of having back pain and being depressed were calculated by logistic regression. Classifications included 16% of men and 30% of women as definite cases, 37% of men and 35% of women as mild cases, and 47% of men and 35% of women as controls. The relative risk (RR) of back pain was 2.3 (95% CI 1.4–3.9) (P < 0.05) in women with definite deformity and 1.5 (95% CI 0.9–2.5) (P > 0.05) in women with mild deformity, as compared with controls. Sixty-four percent of all men had back pain. This prevalence was much higher than figures obtained in a previous survey on low back pain. The prevalence of back pain did not differ by deformity status, but more men with vertebral deformity were on analgesic. There was no significant association between disability due to back pain and vertebral deformity in women. The RR for having a low morale score (of 5 and below) was 2.3 (95% CI 1.3–4.1) (P < 0.05) in women with mild deformity; men with vertebral deformity did not have a low morale. It was concluded that vertebral deformity was associated with significant back pain and psychological morbidity in elderly Chinese women. Although men with vertebral deformity did not report more back pain, more were on analgesics than controls. Received: 2 July 1997 / Accepted: 8 January 1998     

Back pain in adolescents with idiopathic scoliosis: epidemiological study for 43,630 pupils in Niigata City, Japan

There have been a few studies regarding detail of back pain in adolescents with idiopathic scoliosis (IS) as prevalence, location, and severity. The condition of back pain in adolescents with IS was clarified based on a cross-sectional study using a questionnaire survey, targeting a total of 43,630 pupils, including all elementary school pupils from the fourth to sixth grade (21,893 pupils) and all junior high pupils from the first to third year (21,737 pupils) in Niigata City (population of 785,067), Japan. 32,134 pupils were determined to have valid responses (valid response rate: 73.7%). In Niigata City, pupils from the fourth grade of elementary school to the third year of junior high school are screened for scoliosis every year. This screening system involves a three-step survey, and the third step of the survey is an imaging and medical examination at the Niigata University Hospital. In this study, the pupils who answered in the questionnaire that they had been advised to visit Niigata University Hospital after the school screening were defined as Scoliosis group (51 pupils; 0.159%) and the others were defined as No scoliosis group (32,083 pupils). The point and lifetime prevalence of back pain, the duration, the recurrence, the severity and the location of back pain were compared between these groups. The severity of back pain was divided into three levels (level 1 no limitation in any activity; level 2 necessary to refrain from participating in sports and physical activities, and level 3 necessary to be absent from school). The point prevalence was 11.4% in No scoliosis group, and 27.5% in Scoliosis group. The lifetime prevalence was 32.9% in No scoliosis group, and 58.8% in Scoliosis group. According to the gender- and school-grade-adjusted odds ratios (OR), Scoliosis group showed a more than twofold elevated odds of back pain compared to No scoliosis group irrespective of the point or lifetime prevalence of back pain (OR, 2.29; P = 0.009 and OR, 2.10; P = 0.012, respectively). Scoliosis group experienced significantly more severe pain, and of a significantly longer duration with more frequent recurrences in comparison to No scoliosis group. Scoliosis group showed significantly more back pain in the upper and middle right back in comparison to No scoliosis group. These findings suggest that there is a relationship between pain around the right scapula in Scoliosis group and the right rib hump that is common in IS.     

Abdominal draw-in maneuver changes neuromuscular responses to sudden release from trunk loading in patients with non-specific chronic low back pain

BackgroundAbdominal draw-in maneuver (ADIM) has been recommended to achieve appropriate trunk muscle response for patients with non-specific chronic low back pain (CLBP). However, it has remained unclear whether the intervention with ADIM could change the trunk muscle response to sudden release from loading, which is considered to contribute mechanical circumstances to low back pain. The purpose of the present study was to investigate the effects of the intervention with ADIM on electromyography (EMG) activities of trunk muscles following sudden release from loading.MethodsSeventeen subjects with non-specific CLBP participated. Subjects resisted trunk flexion or extension loading in semi-seated position, and then the loading was suddenly released. EMG recordings of 6 trunk muscles were acquired using a wireless surface EMG system. Onset and offset times were calculated from the EMG data. The intervention with ADIM was provided for 4 weeks. The onset and offset times were compared between pre- and post-intervention with ADIM.ResultsAt the post-intervention, the onset of trunk flexors following release from trunk flexion loading became significantly earlier than pre-intervention (P = 0.028). The offset of flexors following release from trunk extension loading of post-intervention was significantly earlier than that of pre-intervention (P = 0.001).ConclusionsWe showed that the intervention with ADIM changed the EMG activity of trunk flexors in response to sudden release from loading. These results suggest a possibility that ADIM might be effective to improve the neuromuscular control of trunk flexors for the treatment of young patients with non-specific CLBP.     

La lombalgie en consultation hospitalière à Lomé (Togo)

Objective. To determine the patterns of low back pain and the conditions associated with this symptom in outpatients attending the rheumatology unit of the Lomé teaching hospital. Methods. Medical records of patients seen over a ten-year period were studied retrospectively. Results. Among the 9065 patients seen, 3204 (35.34%; 1850 women and 1354 men) had low back pain. Mean age at onset was 41 years, and mean duration of low back pain was 3 years. Diseases associated with low back pain were as follows: degenerative spinal disease, n= 3054 (95.32 %); spinal infections, n=79 (2.47 %) ; spondyloarthropathies, n=44 (1.37 %) ; and tumors, n=27 (0.84 %). The features of degenerative spinal disease included back pain (n=1535, 47.91 %), lumbar and radicular pain suggestive of disc herniation (n=1108, 34.58 %), and lumbar and radicular pain with claudication suggestive of lumbar spinal stenosis (n=411, 12.83 %). Schöber’s test was abnormal in 831 of the 1408 patients (59 %) with acute pain or disc herniation. Most patients with lumbar spinal stenosis were women (72.26 %) and were aged 35 to 64 years. Findings suggestive of tuberculosis were present in 62 of the 79 patients with lumbar spinal infection. Among the 44 patients with spondyloarthropathies, 15 had ankylosing spondylitis and 11 had infection with the human immunodeficiency virus (HIV). Multiple myeloma was present in 10 patients and metastatic tumors in eight. Conclusion. Low back pain seems to be as common in sub-Saharan Africa as in occidental countries, with a prevalence of one-third among rheumatology outpatients. Lumbar spinal stenosis seems more common than in the Occident and is mainly observed in woman.  Schöber’s test is not useful for measuring lumbar flexion in Africans. The epidemiology of spondyloarthropathies in sub-Saharan Africa has been changed by the expanding HIV epidemic, despite the low prevalence of HLA B27.     

Long-Term Morbidity and Mortality After a Clinically Diagnosed Vertebral Fracture in the Elderly—a 12- and 22-Year Follow-up of 257 Patients

The objective of this study was to analyze the long-term morbidity and mortality in patients with a clinically diagnosed vertebral fracture. Seventy men with a mean age of 70 years (range 50–91 years) and 187 women with a mean age of 72 years (range 50–96 years) were radiographically diagnosed as having a vertebral fracture in the thoracic or lumbar spine at the Malmö University Hospital (Sweden) during 1979. At the time of a follow-up examination 12 years later, 56 of the 76 patients who were still alive participated in an investigation that evaluated back pain and subjective health status by a questionnaire. Forty-four of these subjects also participated in a further radiologic examination of the spine. Serving as controls were age- and gender-matched subjects from the Malmö cohort of the European Vertebral Osteoporosis Study (EVOS). A mortality analysis was also conducted, covering 22 years following the baseline fracture. There were more female patients, who, in comparison with the controls, 12 years after the diagnosis, had had back pain during the year preceding the follow-up (72% vs 33%, P < 0.001), had current back pain (42% vs. 19%, P = 0.006), and had a subjectively impaired health status (44% vs. 17%, P < 0.001). The corresponding differences in men reached only a borderline significance, for both back pain during the year preceding the follow-up (60% vs. 28%, P = 0.07) and current back pain (40% vs. 15%, P = 0.09), whereas there was no difference in subjective health status. The incidence of new vertebral fractures in individuals with a clinically diagnosed vertebral fracture during the following 12 years was in men 25 per 1,000 person-years and in women 49 per 1000 person-years. There were more women with a new vertebral fracture at the 12-year follow-up examination who, in comparison with women without a new fracture, had had back pain during the year preceding the follow-up examination (90% vs. 50%, age-adjusted P = 0.02) and had current back pain (65% vs. 21%, age-adjusted P = 0.03). Women with a new vertebral fracture at the 12-year follow-up examination had a higher subsequent mortality rate in the next 10 years [age-adjusted hazard ratio 2.8 (95% CI 1.0–7.9)] as compared with women without. The mortality rate during the 22 years following the diagnosis among the male patients was 111.7 per 1,000 person-years as compared with 73.4 per 1,000 person-years among the male population at risk. The mortality rate among the female patients was 95.1 per 1,000 person-years as compared with 62.0 per 1,000 person-years among the female population at risk. We conclude that a clinically diagnosed thoracic or lumbar vertebral fracture in the elderly can be regarded as a risk factor for subsequent, long-term morbidity, especially in women, and for mortality in both genders.     

Intractable chest pain in a patient whose postpneumonectomy space was managed with sulfur hexafluoride

A 50-year-old man who had undergone right pneumonectomy 1 year previously was referred to our department following the sudden onset of severe chest pain. Since the operation, his postpneumonectomy space had been managed with sulfur hexafluoride. On admission, the pressure in the postpneumonectomy space was found to be more than +60 cmH₂O. The chest pain was relieved after the sulfur hexafluoride had been drained and the pressure released. Thus, it is advisable to inject sulfur hexafluoride stepwise into the postpneumonectomy space of patients with long-standing fluid accumulation.     

Low back pain in hospital outpatients in Lomé (Togo)

OBJECTIVE: To determine the patterns of low back pain and the conditions associated with this symptom in outpatients attending the rheumatology unit of the Lomé Teaching Hospital. METHODS: Medical records of patients seen over a ten-year period were studied retrospectively. RESULTS: Among the 9,065 patients seen during the study period, 3,204 (35.34%; 1,850 women and 1,354 men) had low back pain. Mean age at onset was 41 years, and mean duration of low back pain was three years. Diseases associated with low back pain were as follows: degenerative spinal disease, N = 3,054 (95.32%); spinal infections, N = 79 (2.47%); spondyloarthropathies, N = 44 (1.37%); and tumors, N = 27 (0.84%). The patterns of degenerative spinal disease included low back pain (N = 1,535, 47.91%), low back pain with nerve root pain suggestive of disk herniation (N = 1,108, 34.58%), and low back pain with nerve root pain and claudication suggestive of lumbar spinal stenosis (N = 411, 12.83%). Sch?ber's index was abnormal in 831 of the 1,408 patients (59%) with acute pain or disk herniation. Most patients with lumbar spinal stenosis were women (72.26%) and were aged 35 to 64 years. Findings suggestive of tuberculosis were present in 62 of the 79 patients with lumbar spinal infection. Among the 44 patients with spondyloarthropathies, 15 had ankylosing spondylitis and 11 had infection with the human immunodeficiency virus (HIV). Multiple myeloma was present in ten patients and metastatic tumors in eight. CONCLUSION: Low back pain seems to be as common in sub-Saharan Africa as in occidental countries, with a prevalence of one-third among rheumatology outpatients. Lumbar spinal stenosis seems more common than in the occident and is mainly observed in woman. Sch?ber's index is not useful for measuring forward bending of the lumbar spine in Africans. The epidemiology of spondyloarthropathies in sub-Saharan Africa has been changed by the expanding HIV epidemic, despite the low prevalence of the HLA B27 phenotype.     

Similar outcome despite slight clinical differences between lumbar radiculopathy induced by lateral versus medial disc herniations in patients without previous foraminal stenosis: a prospective cohort study with 1-year follow-up

Background contextIt has been claimed that lumbar radiculopathy induced by foraminal disc herniations had poorer outcome and different clinical features, including: 1-more progressive onset, but shorter duration between the first sign and request of medical care; 2-more severe radiculopathy; 3-less frequent/severe back pain; 4-less limitation of straight leg raising (SLR); 5-more frequent neurologic deficiencies; 6-poorer outcome.PurposeTo check whether this still holds true when including only patients without other reasons for foraminal stenosis, that is, whether patients with medial disc herniations had different features and outcome than those with more lateral disc herniations.Study designAll patients hospitalized to treat a lumbar radiculopathy within a 6-month period in two French rheumatology units in 2012 were included in this prospective study each time computed tomography scan or magnetic resonance imaging had already been performed and showed clear disc bulging/herniation but no features of medial or lateral spinal stenosis.Patient sampleFifty-nine patients (31 males, 49 with sciatica only) were included: 31 (53%) had medial disc herniations and 28 (47%) had more lateral herniations (posterolateral in 3, foraminal in 20, and far lateral in 5).Outcome measuresOutcome was assessed by a phone call 1 year after the baseline assessment using a standardized questionnaire. Patients were asked whether they experienced a relapse of their radiculopathy after discharge from the hospital; whether they had been operated or not; whether they felt it had improved or not; whether they felt cured or not; to assess their level of pain radiating in the leg when standing on a 0 to 10 verbal scale; and how long they could walk.MethodsFeatures of patients with medial disc herniations were compared with patients with more lateral herniations.ResultsNo significant differences according to the location of herniations were noticed for the speed of radiculopathy onset, time elapsed since onset, back pain (both lying or standing), and leg pain (both lying or standing), but slight significant differences (t test<0.05) were observed for other items: the 28 patients with lateral herniations were 8 years older (53.4 ±15.8 vs. 45.2±12.6), their herniations involved discs from upper levels of the lumbar spine (above L4–L5: 7/28 vs. 3/31), motor weakness was more frequent (25% vs. 3%), SLR was less restricted (65.0°±24.5° vs. 51.1°±25.7°), DN4 score of neuropathic pain was higher (4.4±2.1 vs. 3.2±1.8), anxiety level was higher (10.3±4.1 vs. 7.9±3.2), length of hospital stay was longer (5.7±2.4 days vs. 4.5±1.4 days), and physician's prognosis of a good outcome was poorer (6.6±2.2 vs. 8.0±1.6). However, at the end of follow-up (12.2±3.3 months), outcome was similar: 37% (vs. 41% for medial herniations) had transiently relapsed, 66% felt finally improved (vs. 63%), and walking capacity was nearly identical despite the fact that only 18% had to be operated (vs. 32% of those with medial herniations).ConclusionsDespite differences in clinical presentation, the outcome of radiculopathy induced by the more lateral lumbar disc herniations was not worse than the outcome of patients with only medial disc herniations. Previous claims of poorer outcome in foraminal herniations might be explained by the inclusion of patients with associated foraminal stenosis.