Neuroimaging in low back pain

Patients commonly present to family physicians with low back pain. Because the majority of patients fully or partially recover within six weeks, imaging studies are generally not recommended in the first month of acute low back pain. Exceptions include patients with suspected cauda equina syndrome, infection, tumor, fracture, or progressive neurologic deficit. Patients who do not improve within one month should obtain magnetic resonance imaging if a herniated disc is suspected. Computed tomographic scanning is useful in demonstrating osseous structures and their relations to the neural canal, and for assessment of fractures. Bone scans can be used to determine the extent of metastatic disease throughout the skeletal system. All imaging results should be correlated with the patient's signs and symptoms because of the high rate of positive imaging findings in asymptomatic persons.     

Is temporomandibular pain in chronic whiplash-associated disorders part of a more widespread pain syndrome?

OBJECTIVES: The prevalence of temporomandibular disorders in patients with chronic whiplash-associated disorder is a controversial issue that may be influenced by the widespread pain character and psychologic distress frequently observed in patients with chronic pain. The aim of this study was to determine the prevalence of temporomandibular disorder pain, widespread pain, and psychologic distress in persons with chronic whiplash-associated disorder pain, using a controlled, single blind study design. The prevalence of temporomandibular disorder pain in the chronic whiplash-associated disorder pain group was compared with 2 control groups: a chronic neck pain group and a no neck pain group. METHODS: From 65 persons, a standardized oral history was taken, a physical examination of the neck and the masticatory system was performed, widespread pain was investigated by tender point palpation, and psychologic distress was measured with a questionnaire (SCL-90). Because the recognition of temporomandibular disorder pain and neck pain remains a matter of debate, 3 well-defined classification systems were used: one based on the oral history, a second on a combination of oral history and pain on active movements and palpation, and a third one based on a combination of oral history and function tests. RESULTS: Irrespective of the classification system used, the chronic whiplash-associated disorder pain group more often suffered from temporomandibular disorder pain (0.001相似文献   

Widespread sensory hypersensitivity is a feature of chronic whiplash-associated disorder but not chronic idiopathic neck pain

OBJECTIVES: To investigate sensory changes present in patients with chronic whiplash-associated disorders and chronic idiopathic neck pain using a variety of quantitative sensory tests to better understand the pain processing mechanisms underlying persistent symptoms. METHODS: A case control study was used with 29 subjects with chronic whiplash-associated disorders, 20 subjects with chronic idiopathic neck pain, and 20 pain-free volunteers. Pressure pain thresholds were measured over the articular pillars of C2-C3, C5-C6, the median, radial, and ulnar nerve trunks in the arm and over a remote site, the muscle belly of tibialis anterior. Heat pain thresholds, cold pain thresholds, and von Frey hair sensibility were measured over the cervical spine, tibialis anterior, and deltoid insertion. Anxiety was measured with the Short-Form of the Spielberger State Anxiety Inventory. RESULTS: Pressure pain thresholds were decreased over cervical spine sites in both subject groups when compared with controls (P < 0.05). In the chronic whiplash-associated disorders group, pressure pain thresholds were also decreased over the tibialis anterior, median, and radial nerve trunks (P < 0.001). Heat pain thresholds were decreased and cold pain thresholds increased at all sites (P < 0.03). No differences in heat pain thresholds or cold pain thresholds were evident in the idiopathic neck pain group at any site compared with the control group (P > 0.27). No abnormalities in von Frey hair sensibility were evident in either neck pain group (P > 0.28). DISCUSSION: Both chronic whiplash-associated disorders and idiopathic neck pain groups were characterized by mechanical hyperalgesia over the cervical spine. Whiplash subjects showed additional widespread hypersensitivity to mechanical pressure and thermal stimuli, which was independent of state anxiety and may represent changes in central pain processing mechanisms. This may have implications for future treatment approaches.     

Are smooth pursuit eye movements altered in chronic whiplash-associated disorders? A cross-sectional study

OBJECTIVE: To evaluate whether smooth pursuit eye movements differed between patients with long-lasting whiplash-associated disorders and controls when using a purely computerized method for the eye movement analysis. DESIGN: Cross-sectional study comparing patients with whiplash-associated disorders and controls who had not been exposed to head or neck trauma and had no notable neck complaints. METHODS: Smooth pursuit eye movements were registered while the subjects were seated with and without rotated cervical spine. SUBJECTS: Thirty-four patients with whiplash-associated disorders with symptoms more than six months after a car collision and 60 controls. RESULTS: Smooth pursuit eye movements were almost identical in patients with chronic whiplash-associated disorders and controls, both when the neck was rotated and in the neutral position. CONCLUSION: Disturbed smooth pursuit eye movements do not appear to be a distinct feature in patients with chronic whiplash-associated disorders. This is in contrast to results of previous studies and may be due to the fact that analyses were performed in a computerized and objective manner. Other possible reasons for the discrepancy to previous studies are discussed.     

Spontaneous bilateral vertebral artery dissections: case report and literature review.

Vertebral artery dissection (VAD) has been increasingly identified as a cause of ischemic stroke in young adults. We report the clinical and radiographic findings in a case of spontaneous bilateral VADs and review the literature on the causes, pathophysiology, diagnostic considerations, and treatment options for VAD. A 29-year-old man was admitted to our hospital after sudden onset of headache and nuchal rigidity that progressed to a posterior lateral medullary syndrome in a 2-week period. The diagnosis of bilateral VADs was based on findings on cranial magnetic resonance imaging and conventional angiography. The patient was given anticoagulant therapy and had no further neurologic deterioration. The differential diagnosis of craniocervical pain in young patients should include arterial dissection of the neck because early diagnosis and treatment may reduce the chances of long-term neurologic sequelae.     

The psychological profiles of patients with whiplash-associated headache

Headache often compounds chronic neck pain following whiplash injury. To better understand post-traumatic headache, the SCL-90-R symptom checklist was used to determine the psychological profiles of patients with whiplash-associated headache and of patients with whiplash-associated neck pain without headache. The psychological profiles of these patients were compared with previously published SCL-9O-R profiles of patients with post-traumatic and nontraumatic headache, and of the normal population. Patients with whiplash-associated headache were not significantly different from those with other forms of post-traumatic headache or with whiplash-associated neck pain without headache. However, when patients with whiplash-associated headache and patients with nontraumatic headache were compared to normal data, significant differences emerged. Patients with nontraumatic headache exhibited higher scores on all subscales, whereas patients with whiplash-associated headache differed from the normal sample only on somatization, obsessive-compulsive, depression and hostility subscales, and the global severity index. These differences imply that patients with whiplash-associated headache suffer psychological distress secondary to chronic pain and not from tension headache and generalized psychological distress.     

Bildgebende Diagnostik bei Wirbels?ulenbeschwerden

Low back pain and neck pain are two of the most commonly reported complaints. In cases of non-specific pain, diagnostic imaging is not recommended within the first 4-6 weeks. If risk factors for serious disorders (red flags) can be identified, further diagnostic imaging is required depending on the suspected underlying pathology. Plain radiography is the most commonly used imaging procedure because of availability and low cost but with the disadvantage of low sensitivity. In cases of traumatic neck pain, computed tomography is the best imaging procedure to exclude bone-related pathologies. In other cases, magnetic resonance imaging is the preferred procedure due to a better visualization of the soft tissue surrounding bone. Bone scintigraphy should be used if signs of a systemic or multifocal disease are present because of the whole body visualization and great sensitivity.     

Headache and Neck Pain: The Warning Symptoms of Vertebral Artery Dissection

SYNOPSIS
The clinical features of headache and neck pain in 14 patients with extracranial vertebral artery dissection proven by angiography or magnetic resonance imaging are reported. Pain was always located on the side of the dissected vertebral artery. Whereas eleven patients had head and posterior neck pain, the others had either only posterior neck pain, no change of a chronic pre-existing headache or no pain at all. Pain started suddenly, was of sharp quality and severe intensity, different from any previously experienced headache. Following acute onset, the time course of pain was monophasic with gradual remission of a persistent headache lasting one to three weeks. A delay between onset of head or posterior neck pain and onset of neurologic dysfunction was noted in 12 patients and was less than one day and between one day and three weeks in six each. Report of this distinct type of pain, although non-specific as an isolated symptom, should raise suspicion of an underlying vertebral artery dissection. Early confirmation of this diagnosis and subsequent anticoagulation if dissection does not extend intracranially may help prevent vertebro-basilar ischemic deficits.     

Legionnaire's disease associated with acute encephalitis and arrhythmia

OBJECTIVE: To report an unusual, life-threatening combination of neurologic, cardiac, and gastrointestinal symptoms in the presence of a community-acquired pneumonia. DESIGN: Case report. SETTING: University hospital. PATIENT: Previously healthy young male. INTERVENTION: Diagnostic fiberoptic bronchoscopy, lumber puncture, magnetic resonance imaging of the brain, and institution of systemic antibiotics. MAIN RESULT: Gradual clinical improvement of a multiple-system illness. CONCLUSION: Legionellosis should be considered in the differential diagnosis of patients presenting with neurologic, cardiac, and gastrointestinal symptoms, particularly in the presence of radiographic pneumonia. Furthermore, Legionella meningoencephalitis may present with findings on magnetic resonance imaging previously thought to be characteristic of herpes encephalitis.     

Intracranial Hypotension Following Motor Vehicle Accident: An Overlooked Cause of Post‐Traumatic Head and Neck Pain?

Abstract:   Motor vehicle accidents result in many patients with chronic head and neck pain, some of which meet the criteria for a "whiplash syndrome." The cervical zygapophysial joint synovium, muscular, and ligamentous strains and other anatomical sites are often implicated in the pathophysiology of these cases. Some patients have a characteristic constellation of vague neurological symptoms, often including headache, posterior neck discomfort, dizziness, nausea, and sometimes visual changes. Recently presented research has noted that some patients who have a whiplash-associated disorder have imaging findings consistent with a low-pressure cerebrospinal fluid leak. Some of these patients respond favorably to high-volume epidural blood patch. The following case presentation focuses on the differential diagnosis of a post-traumatic headache syndrome, specific imaging findings, and treatment strategies.     

Low back pain due to spinal chronic subdural hematoma mimicking intradural tumor in the lumbar area: a case report and literature review.

Although magnetic resonance imaging has dramatically enhanced the ability to diagnose spinal mass lesions, some lesions remain difficult to diagnose. We report a spinal chronic subdural hematoma that comprised the cauda equina ventrally in the lumbar area in a 51-year-old man who was under anticoagulant therapy. Low back pain was the only symptom of the patient after sports activity. Surgical treatment was performed 2 months after the onset of symptoms. Intraoperative view showed chronic subdural hematoma with abnormal enlarged dural vascularization. The patient had no preoperative and postoperative neurologic deficit. Low back pain with sudden onset after minor trauma refractory to medical treatment must be investigated with magnetic resonance imaging in patients under anticoagulant therapy for spinal hematoma because of the possibility of spinal chronic subdural hematoma.     

Emergency Department Presentation of Patients with Conversion Disorder

Objective: To describe the presenting symptoms and other features of ED patients diagnosed as having conversion disorder.
Methods: A retrospective chart review was carried out on the records of ED patients who had had final ED or in-hospital diagnoses of conversion disorder. Cases from 1982 to 1992 at a 566-bed rural tertiary care hospital with a residency program in emergency medicine were reviewed for patient age and gender, presenting signs and symptoms, ED diagnostic evaluation, disposition, and comorbidity.
Results: Of 42 patients who had conversion disorder diagnoses, 24 were women and 18 were men. Twenty-one (50%) of the patients were diagnosed in the ED, and of those patients, ten were released home from the ED. Patient age ranged from 5 to 70 years, with a mean age of 33 years for women and 34 years for men. Most clinical symptoms mimicked neurologic disorders (weakness, pain, seizurelike activity, loss of consciousness, etc). Thirty patients (71%) received laboratory studies in the ED and two others received laboratory studies on admission. Seventeen (40%) patients had computed tomography of the head and five (12%) patients had magnetic resonance imaging of the head. Twelve (29%) patients had previous histories of psychiatric disorders, four (10%) had histories of alcohol and drug abuse, two (5%) had prior conversion reactions, three (7%) had chronic illnesses, and four (10%) had been victims of previous head trauma.
Conclusion: Patients with conversion disorder in the ED usually present with neurologic symptoms and undergo multiple diagnostic tests. Comorbidity is common. Early psychiatric evaluation may assist in the diagnosis and evaluation of patients with suspected conversion disorder in the ED.     

Cervical spinal epidural hematoma mimics acute ischemic stroke

Spinal epidural hematoma is an accumulation of blood in the epidural space that can mechanically compress the spinal cord. It is an uncommon condition, and most cases occur spontaneously. Detailed evaluation of neurologic deficit and detailed history taking are important tools for early diagnosis, and magnetic resonance imaging is currently the diagnostic method of choice. Prompt surgical intervention is important in achieving positive clinical outcomes. Spinal epidural hematoma usually comes with acute, severe pain with radiation to the extremities and may be accompanied with severe neurologic deficit. Common neurologic signs include paraparesis and quadriparesis. Here, we report 2 cases of cervical spinal epidural hematoma with sudden onset of neck pain, followed by the development of unilateral limbs weakness and respiratory distress. Both patients were initially suspected to have acute ischemic stroke and were considered using intravenous thrombolytic therapy with recombinant tissue plasminogen activator as treatment. Cervical spinal epidural hematoma was confirmed after obtaining magnetic resonance imaging. Patients with this uncommon presentation must be carefully distinguished from acute stroke. This article aimed to highlight the potential pitfalls in diagnosing acute hemiparesis with no cranial nerves deficits and the importance of clinical suspicion.     

Chronic shoulder pain: part I. Evaluation and diagnosis

Shoulder pain is defined as chronic when it has been present for longer than six months. Common conditions that can result in chronic shoulder pain include rotator cuff disorders, adhesive capsulitis, shoulder instability, and shoulder arthritis. Rotator cuff disorders include tendinopathy, partial tears, and complete tears. A clinical decision rule that is helpful in the diagnosis of rotator cuff tears includes pain with overhead activity, weakness on empty can and external rotation tests, and a positive impingement sign. Adhesive capsulitis can be associated with diabetes and thyroid disorders. Clinical presentation includes diffuse shoulder pain with restricted passive range of motion on examination. Acromioclavicular osteoarthritis presents with superior shoulder pain, acromioclavicular joint tenderness, and a painful cross-body adduction test. In patients who are older than 50 years, glenohumeral osteoarthritis usually presents as gradual pain and loss of motion. In patients younger than 40 years, glenohumeral instability generally presents with a history of dislocation or subluxation events. Positive apprehension and relocation are consistent with the diagnosis. Imaging studies, indicated when diagnosis remains unclear or management would be altered, include plain radiographs, magnetic resonance imaging, ultrasonography, and computed tomography scans. Plain radiographs may help diagnose massive rotator cuff tears, shoulder instability, and shoulder arthritis. Magnetic resonance imaging and ultrasonography are preferred for rotator cuff disorders. For shoulder instability, magnetic resonance imaging arthrogram is preferred over magnetic resonance imaging.     

Acute and chronic whiplash disorders--a review.

OBJECTIVE: This review examines acute and chronic whiplash-associated disorders to facilitate assessment, treatment and rehabilitation for further research and evidence-based practices. DESIGN: A review of the literature. RESULTS AND CONCLUSION: Whiplash-associated disorders account for a large proportion of the overall impairment and disability caused by traffic injuries. Rarely can a definite injury be determined in the acute (or chronic) phase. Crash-related factors have been identified, and several trauma mechanisms possibly causing different injuries have been described. Most whiplash trauma will not cause injury, and the majority of patients (92-95%) will return to work. Litigation is not a major factor. Cognitive impairments are not the same as brain injury. Variables such as pain intensity, restricted motion, neurological symptoms and signs, together with central nervous system symptoms can be used to predict a situation with risk of remaining complaints. Influences of other factors--the same as for other chronic pain conditions--also exist. Persistent/chronic pain is not merely acute pain that persists over time; changes occur at different levels of the pain transmission system. Chronic whiplash-associated disorders are associated with problems concerning social functioning, daily anxieties and satisfaction with different aspects of life. Adequate information, advice and pain medication together with active interventions might be more effective in the acute stage. Early multidisciplinary rehabilitation focusing on cognitive-behavioural changes might be of value. To develop specific treatment and rehabilitation, it is important to identify homogenous subgroups.     

Conversion disorder presenting as hemiplegia and hemianesthesia with loss of neurologic reflexes: a case report

Conversion disorders can present with a variety of sensorimotor signs and symptoms. We present the case of a young woman who presented with sudden onset hemiplegia and hemianesthesia including unilateral loss of deep tendon reflexes, Babinski reflex, and loss of rectal tone with bladder incontinence. The loss of rectal tone, loss of deep tendon reflexes, and a flaccid Babinski reflex are unusual signs in conversion disorders. A thorough medical workup including x-rays, CT scans, and magnetic resonance imaging revealed no organic causes for the neurologic deficits. Before the onset of symptoms, the patient was emotionally upset during an argument, which may have provided the psychologic stressor necessary for a conversion disorder. The young woman gradually regained full neurologic function over the next 14 hours. Conversion disorders should be considered when the neurologic findings do not correspond to known anatomic or physiologic pathways, although a thorough medical investigation must be performed to search for organic causes.     

A randomized study of new sling exercise treatment vs traditional physiotherapy for patients with chronic whiplash-associated disorders with unsettled compensation claims.

BACKGROUND: Many patients with chronic whiplash-associated disorders have reduced neuromuscular control of the neck and head. It has been proposed that a new sling exercise therapy may promote neuromuscular control of the neck. OBJECTIVES: To compare the effects of traditional physiotherapy vs traditional physiotherapy combined with a new sling exercise therapy on discomfort and function in patients with chronic whiplash-associated disorders who have unsettled compensation claims; and to investigate possible additional effects of guided, long-term home training. DESIGN: A randomized multi-centre trial with 4 parallel groups. METHODS: A total of 214 patients were assigned randomly to 4 treatment groups, and received either traditional physiotherapy with or without home training, or new sling exercise therapy with or without home training. Outcome measures were pain, disability, psychological distress, sick leave and physical tests. RESULTS: A total of 171 patients (80%) completed the study. There were no important statistical or clinical differences between the groups after 4 months of treatment. There was a small statistically significant effect at 12-month follow-up in both groups with home training regarding pain during rest (p = 0.05) and reported fatigue in the final week (p = 0.02). CONCLUSION: No statistically significant differences were found between the traditional physiotherapy group and the new sling exercise group, with or without home training. Since the groups were not compared with a control group without treatment, we cannot conclude that the studied treatments are effective for patients with whiplash-associated disorder, only that they did not differ in our study.     

Is cervical spinal manipulation dangerous?

OBJECTIVE: Concern about cerebrovascular accidents after cervical manipulation is common. We report a case of cerebrovascular infarction without sequelae. CLINICAL FEATURES: A 39-year-old man with nonspecific neck pain was treated by his general practitioner with cervical manipulation. INTERVENTION AND OUTCOME: This immediately elicited severe headache and neurologic symptoms that disappeared completely within 3 months despite permanent signs of a complete left-sided cerebellar infarction on computed tomography and magnetic resonance imaging. At 7-year follow-up the patient was fully employed, and repeated magnetic resonance imaging still showed infarction of the left cerebellar hemisphere. However, the patient remained completely free of neurologic symptoms, and color duplex ultrasonography showed normal cervical vessels, including patent vertebral arteries. CONCLUSION: It appears that the risk of cerebrovascular accidents after cervical manipulation is low, considering the enormous number of treatments given each year, and very much lower than the risk of serious complications associated with generally accepted surgery. Provided there is a solid indication for cervical manipulation, we believe that the risk involved is acceptably low and that the fear of serious complications is greatly exaggerated.     

Transcranial sonography and vertebrobasilar insufficiency

OBJECTIVE: The objective was to discuss a case illustrating the role of transcranial Doppler sonography in the screening and treatment of a patient with intermittent vertebral artery brainstem ischemia. CLINICAL FEATURES: A 28-year-old woman had neck pain, arm pain, headaches, and dizziness. Her symptoms occurred intermittently over several years. Past care had provided little relief. De Kleyn's test, transcranial Doppler sonography, and magnetic resonance imaging/magnetic resonance angiography helped establish a diagnosis of vertebrobasilar syndrome. INTERVENTION AND OUTCOME: The patient was referred for neurosurgical evaluation. She subsequently chose to be treated with spinal manipulative therapy. Her neck pain, headaches, and radicular symptoms resolved. The dizzy spells abated to a tolerable level. The neurosurgeon subsequently re-evaluated the patient and recommended that surgery not be performed. CONCLUSIONS: This illustrates a case of extra-arterial mechanical compression of the vertebral arteries documented by transcranial Doppler sonography procedures. Brainstem symptoms were correlated with a documented perfusion deficit during cervical positional testing. This case also demonstrated that spinal manipulative therapy may be safely used on patients with vertebrobasilar insufficiency when the biomechanics and related flow studies are elucidated.     

Headache in Ehlers-Danlos syndrome

OBJECTIVE: Ehlers-Danlos Syndrome (EDS) is a complex hereditary connective tissue disorder with neurologic manifestations that include cerebrovascular disorders and chronic pain. The clinical data collected on 18 patients with EDS and chronic headaches is reported. PROCEDURE: Clinical history, neurologic examination, computerized tomography of the head, magnetic resonance imaging (MRI) of the brain, and electroencephalogram (EEG). Headaches were classified according to the International Headache Society and the patients were followed by the author for a minimum of 2 years. FINDINGS: Four patients had migraine with aura, four had migraine without aura, four had tension headaches, four had a combination of migraine and tension headaches, and two had post-traumatic headaches. Nine patients exhibited blepharoclonus but none had history of seizures and their EEGs were normal, ruling out eye closure epilepsy. Although one patient had a small right frontal angioma, a second had Arnold Chiari malformation type I, and a third had an old stroke, headaches did not clinically correlate with their central nervous system (CNS) lesions. CONCLUSION: Chronic recurrent headaches may constitute the neurologic presentation of EDS in the absence of structural, congenital, or acquired CNS lesions that correlate with their symptoms. Individuals with EDS may be prone to migraine due to an inherent disorder of cerebrovascular reactivity or cortical excitability. Additional studies are needed to elucidate the pathogenesis of headaches in EDS.