Facet joint degeneration as a cause of low back pain

Recognizing that not all patients with low back pain have lumbar disc disease, the authors began to inject facet joints in June 1982 and have experience now with 21 patients, each injected under fluoroscopic control with a mixture of local anesthetic and steroid. One technical problem occurred when large osteophytes blocked access to the facet joints. Otherwise, there were no complications and minimal morbidity. Most patients (15 of 20; 75%) had an initial response, but a much smaller number (six of 18 followed more than three months; 33%) had a lasting response. Repeat injections, when done, always led to temporary improvement but rarely to lasting relief (one of five; 20%). Three factors characterized the patients: a negative screening examination for other causes of back pain or sciatica; back pain with tenderness localized over one or more facet joints; and radiologic changes of degenerative joint disease within the facet joints. Facet joint disease may be a significant cause of low back pain. The above three criteria are useful in clinical identification of patients with this problem. Facet joint injections play an important role in the diagnosis and treatment of low back pain.     

Natural course of desmoid-type fibromatosis

Background Desmoid-type fibromatosis is a locally aggressive tumor known to have high potential for local recurrence after resection, while it exhibits self-limiting behavior and shows growth arrest or spontaneous regression in many patients. Thus, its natural course is not well known, and the proper treatment has not yet been established. Methods We retrospectively reviewed clinical outcome and changes in tumor size in 11 consecutive patients with extremity and trunk desmoid-type fibromatoses, who were basically observed without any treatment after diagnosis. Results For two patients in whom the tumors were initially incorrectly diagnosed as other tumors, surgical resection was performed. For another two patients, surgical resections were performed in the follow-up periods due to tumor enlargement or joint contracture. In all four patients who underwent surgery, tumors recurred shortly after resection and re-resection was not performed. During the follow-up periods with a median length of 56 months, ten tumors eventually stopped growing, and three of them regressed spontaneously. At the time of final follow-up, ten patients were alive with residual disease without severe morbidity. In one patient, the tumor enlarged to over 30 cm in diameter with a substantial functional deficit. Conclusions Simple observation is a noninvasive and function-preserving treatment for desmoid-type fibromatosis.     

硬膜外静脉丛曲张致腰腿痛研究进展

临床上引起腰腿痛的病因较多,一般认为来源于发生退变的椎间盘及周边的韧带和肌肉等组织,其中硬膜外静脉丛曲张是一个长期被忽视的病因。硬膜外静脉丛广泛分布在椎管内侧与硬膜、神经根直接相邻,并作为腔静脉辅助引流系统在体液循环中发挥重要作用。由于骨性椎管容积相对固定,所以若硬膜外静脉丛严重迂曲、扩张则有可能直接挤压硬膜、马尾或者相应节段神经根,导致类似椎间盘突出症或椎管狭窄症的临床症状。因扩张的静脉丛缺乏特异的影像学表现,在临床上很难准确地与椎间盘突出症或椎管狭窄症等相鉴别,故极易被忽视。然而,扩张的静脉丛迂曲且壁薄,术中很容易出血,增加手术难度,同时也会导致如术后硬膜外血肿等相关并发症。虽然对硬膜外静脉丛的研究开展较早,且已经被纳入大多数的解剖学图谱中,但临床医生对于硬膜外静脉丛的解剖结构、形态学特征、临床意义和影像学检查等细节仍然所知甚少。通过对以上几个方面进行文献综述,介绍硬膜外静脉丛的最新研究进展。     

Entrapment of middle cluneal nerves as an unknown cause of low back pain

Entrapment of middle cluneal nerves induces low back pain and leg symptoms. The middle cluneal nerves can become spontaneously entrapped where this nerve pass under the long posterior sacroiliac ligament. A case of severe low back pain, which was completely treated by release of the middle cluneal nerve, was presented. Entrapment of middle cluneal nerves is possibly underdiagnosed cause of low-back and/or leg symptoms. Spinal surgeons should be aware of this clinical entity and avoid unnecessary spinal surgeries and sacroiliac fusion. This paper is to draw attention by pain clinicians in this unrecognized etiology.     

The psoas muscle as cause of low back pain in infantile cerebral palsy

Psoas muscle spasticity is hypothesised as a rare cause of low back pain in patients with infantile cerebral palsy. The authors describe a new manoeuvre for the study of psoas tenderness and ultrasound (US)-guided transabdominal botulinum toxin injection technique. A possible causal relationship between psoas tension and low back pain was found incidentally in two examined cases. In subsequent patients, botulinum toxin was injected and, in cases of disappearance of symptoms, the psoas tendon was sectioned at the pelvic brim with definitive disappearance of pain. The relationship between psoas tension and low back pain in patients with infantile cerebral palsy seems likely, given the result in the four patients.     

Hematocolpos as a cause of back pain in premenarchal adolescents

Persistent low back pain in children demands thorough investigation. An unusual cause of such discomfort is hematocolpos secondary to imperforate hymen in premenarchal girls. Experience with four patients whose initial primary symptom was low back pain has been documented. All had large pelvic masses with greater than 400 ml of old blood being drained at hymenotomy in all patients. Irritation of the sacral plexus or nerve roots is postulated as a mechanism for the referred back pain. Hematocolpos should be included in the differential diagnosis of prepubertal girls who have low back pain.     

Free gas in the spinal canal as cause of low back pain and sciatica

We describe two patients suffering from sciatica for the presence of epidural gas compressing the nerve root. Previously, only one patient had undergone spinal surgery. The aim of this report is to describe the origin and the treatment of radiculopathies caused by epidural gas. Received: 5 December 2000/Accepted in revised form: 2 June 2000     

Cancer as a cause of low back pain in a patient seen in a direct access physical therapy setting

STUDY DESIGN: Resident's case problem. BACKGROUND: This paper describes the clinical course of a patient with low back pain (LBP) and left lower extremity pain and tingling, and how the physical therapist used clinical examination findings and a lack of improvement with conservative measures to initiate further medical evaluation, which resulted in a diagnosis of cancer as the primary cause of the patient's low back and hip pain. DIAGNOSIS: A 45-year-old man with chief complaints of left-sided LBP, left posterior thigh pain, and tingling along the anterolateral aspect of his left lower extremity was initially seen by a physical therapist in a direct access setting. Several components of the patient's history and physical examination were consistent with a mechanical neuromusculoskeletal dysfunction. However, there were signs and symptoms present that may have been suggestive of more serious underlying disease. Specifically, the patient's most intense pain was in the evening and into the night and an atypical pattern of restricted motion at the left hip was noted. Therefore, the physical therapist recommended that the patient schedule an appointment with his physician for medical evaluation. A short-term course of physical therapy treatment was also undertaken to address neuromusculoskeletal impairments. Despite 5 physical therapy visits over the course of a month, while the patient waited for his scheduled physician appointment, the patient's condition gradually worsened. After medical evaluation, the patient was eventually diagnosed with small cell carcinoma of the lung, with metastases to the spine and pelvis. Despite 2 cycles of chemotherapy, the patient succumbed to the cancer 5 months after he was first seen in physical therapy. DISCUSSION: It is important that physical therapists have an understanding of the clinical findings associated with the presence of serious underlying diseases causing LBP, as this information provides guidance as to when communication with the patient's physician is warranted.     

Mesenteric fibromatosis: a rare cause of acute abdominal pain

A 45-year-old man, with a previous history of astrocytoma, presented with diffuse abdominal pain. A CT scan was non-specific and the pain worsened; his abdomen became peritonitic on examination. An exploratory laparotomy was performed, and a large small bowel mesenteric mass was found together with an associated haematoma. Subsequent histology showed the tumour to be a benign fibromatosis, and the patient recovered uneventfully. There were no reports in the literature of any association between astrocytomas and fibromatosis. Mesenteric fibromatosis is a rare tumour often associated with Gardner's syndrome. It can present in a multitude of ways and the only definite treatment is surgical resection.     

The myth of lumbar instability: the importance of abnormal loading as a cause of low back pain

Spinal fusion became what has been termed the “gold standard” for the treatment of mechanical low back pain, yet there was no scientific basis for this. Operations of fusion for low back pain were initially done at the beginning of the last century for back pain thought to be related to congenital abnormalities or for past spinal infection. The recognition of the disc as a cause of sciatica, commonly associated with back pain, and the recognition that a degenerate disc led to abnormal movement suggested the concept that this abnormal movement was the cause of pain, and this abnormal movement came to be called “instability”. Much biomechanical expertise confirmed the fact that degenerate discs led to abnormal movement, there were many hypothesis as to why this caused pain. However clinical results of fusion for back pain were unpredictable. The failure of pedicle screws and cage fusion to improve the clinical results of fusion despite near 100% fusion success, and the introduction of “flexible stabilization” and artificial discs, which demonstrated that despite the often unpredictable movement permitted by of these devices, clinical success was similar to fusion, directed attention to the other role of the disc, that of load transfer, which these devices also affected. Abnormal load transfer was already known to be critical in other joints in the body and had led to the use of osteotomy to realign joints. The relevance of load transfer to the future design of spinal implants used in the treatment of low back pain is discussed, and some finite element studies are reported demonstrating the likely effect of abnormal loading beneath an incompletely incorporated plate of an artificial disc, perhaps explaining in part the somewhat disappointing clinical results to date of the implantation of artificial discs.     

Exercise as a treatment for chronic low back pain.

BACKGROUND CONTEXT: Exercise is a widely prescribed treatment for chronic low back pain, with demonstrated effectiveness for improving function and work. PURPOSE: The goal of this article is to review several key aspects about the safety and efficacy of exercise that may help clinicians understand its utility in treating chronic back pain. STUDY DESIGN/SETTING: A computerized literature search of MEDLINE was conducted using "exercise," "fitness," "back pain," "backache" and "rehabilitation" as search words. Identified abstracts were scanned, and useful articles were acquired for further review. Additional references were acquired through the personal collections of research papers possessed by the authors and by reviewing prior review articles on this subject. These final papers were scrutinized for data relevant to the key aspects about exercise covered in this article. RESULTS: For people with acute, subacute or chronic low back pain, there is no evidence that exercise increases the risk of additional back problems or work disability. To the contrary, current medical literature suggests that exercise has either a neutral effect or may slightly reduce risk of future back injuries. Exercise can be prescribed for patients with chronic low back pain with three distinct goals. The first and most obvious goal is to improve or eliminate impairments in back flexibility and strength, and improve performance of endurance activities. There is a large body of evidence confirming that this goal can be accomplished for a majority of patients with chronic low back pain. The second goal of exercise is to reduce the intensity of back pain. Most studies of exercise have noted overall reduction in back pain intensity that ranges from 10% to 50% after exercise treatment. The third goal of exercise is to reduce back pain-related disability through a process of desensitization of fears and concerns, altering pain attitudes and beliefs and improving affect. The mechanisms through which exercise can accomplish this goal have been the subject of substantial research. CONCLUSIONS: Exercise is safe for individuals with back pain, because it does not increase the risk of future back injuries or work absence. Substantial evidence exists supporting the use of exercise as a therapeutic tool to improve impairments in back flexibility and strength. Most studies have observed improvements in global pain ratings after exercise programs, and many have observed that exercise can lessen the behavioral, cognitive, affect and disability aspects of back pain syndromes.     

Sacral extradural arachnoid cyst: a rare cause of low back and perineal pain

Sacral extradural arachnoid cysts are rare. The clinical and radiological features of this condition are characteristic. One such rare case with low back and perineal pain is presented and the literature is reviewed. This patient presented with pain in the low back and perineal region, which was aggravated by standing, walking and straining. The patient also had numbness in both lower limbs, precipitated by standing and walking. Both the symptoms were relieved by lying down. Magnetic resonance imaging (MRI) revealed a sacral extradural arachnoid cyst. Sacral laminectomy with opening of the arachnoid cyst and ligation of the fistulous tract was done. Postoperatively, there was complete clinical recovery. Though rare, this entity should be considered in the differential diagnosis of low back and perineal pain. Surgical treatment is curative.