Back Pain Causes and Treatments

My Back Pain Coach

My Back Pain Coach is a video series developed for people like you who want to once and for all live the life they had before the onset of excruciating back pain. You can call it a miracle because, in just 8 movements that take roughly 16 minutes, your life long bone breaking back pain will vanish in the thin air. That's not all, the eight movements are produced to strengthen your core, especially your abs for better balance and stability, improve your posture for the times to come, walk taller as your contracted and tightened muscles are relaxed, and increase blood flow, oxygen, and nutrients to your spine and the rest of the body so that all of the aching areas receive their deserved share of pain soothing chemicals. The beauty of these movements is that they are not anything like you've been doing in the traditional exercises such as Yoga, Pilates, massage therapy, and exercises recommended by physical therapists. The trustworthiness of this program can be judged from the fact that it has been developed by a trainer of Olympians, working in Serbia, and produced by fitness trainer. Besides the main video series, three bonuses are also given for free. Read more here...

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Back pain

More than half the population will suffer back pain at some time in their lives. With advancing age, spinal degenerative changes are common, but these changes do not correlate well with back pain symptoms. Unfortunately, treatment is not available for most degenerative changes there is little evidence that replacing worn discs or fusing spinal segments has long-term beneficial effects. Most important is early exclusion of specific causes of back pain. These are New episodes of back pain should be properly investigated and the patient reassured if appropriate. Early mobilization and activity are important to prevent dysfunction and guarding of movements of the back. Even 2 days of bed rest may be harmful. Most patients are given advice to rest until the pain subsides, and investigation is undertaken only after a long delay. This leads to unnecessary suffering and dissatisfaction with the medical profession. Treatment involves acknowledging the pain, education, gradual return to...

Discogenic Back Pain

Back pain arising from the disc may be acute or slow in onset but become chronic, persistent, intractable, and disabling. The pain may be caused by inflammatory substances from the nucleus pulposis leaking into the surrounding tissues and inflaming the meninges. Disruption of the concentric collagenous fibers of the annulus fibrosus can also create pain. Innervation of the annulus from the recurrent meningeal nerve and ventral ramus of the somatic spinal nerves are sources of the pain. Disc desiccation or disruption of the collagenous fibers can promote annular fissures. Repetitive stress and microtears may lead to trabecular biomechanical disruption, and these changes may include collagen revision as seen with Scheuermann's syndrome and discitis. Herniation can pinch one or two nerves and cause pain. In the lumbar region, the discomfort begins in the back and shoots down the leg. The discomfort from the herniation may be experienced in activity or inactivity, which distinguishes...

Infection in Pregnancy

Mild impairment of cell-mediated immunity occurs during gestation, and pregnant women are prone to developing listerial bacteremia with an estimated 17-fold increase in risk (Weinberg 1984 Mylonakis et al. 2002). Listeriae proliferate in the placenta in areas that appear to be unreachable by usual defense mechanisms, and cell-to-cell spread facilitates maternal-fetal transmission (Bakardjiev et al. 2005). For unexplained reasons, CNS infection, the most commonly recognized form of listeriosis in other groups, is extremely rare during pregnancy in the absence of other risk factors (Ciesielski et al. 1988 Gellin et al. 1994 Bucholz and Mascola 2001). Bacteremia manifests clinically as an acute febrile illness, often accompanied by myalgia, arthralgia, headache, and backache. Illness may occur at any time during pregnancy but usually occurs in the third trimester, probably related to the major decline in cell-mediated immunity seen at 26-30 weeks of gestation (Weinberg 1984). Twenty-two...

Have You Considered Or Gathered Information About Medicalorganic Etiology

The nonmedical clinician is advised to inquire of clients as to whether any medical evaluation of their condition has been performed prior to initiating an hypnotic intervention. Common presentations to the hypnotherapist such as headaches, insomnia, and back pain may have organic etiologies that require surgical or pharmaceutical treatment (Olness & Libbey, 1987). A hasty hypnotic intervention may delay proper diagnosis, cloud symptoms or actually worsen a client's condi

Spinal Canal Stenosis

Central spinal canal stenosis may be developmental, acquired, or a combination of the two. Developmental stenosis is relatively uncommon and is estimated to account for approx 15 of all cases of spinal stenosis. It may be idiopathic or related to a more generalized disorder affecting the skeletal system, as in the case of the mucopolysaccharidoses or Down's syndrome. The idiopathic variant may selectively involve the lumbar region or may be generalized. It results from the formation of short pedicles with a resulting decrease in the cross-sectional diameter of the central canal. In isolation, this abnormality is generally not symptomatic but renders the patient more susceptible to relatively mild derangements of the disc or posterior elements. Acquired central spinal stenosis may be caused by various abnormalities related to degeneration of the intervertebral disc (vertebral osteophyte, circumferential disc bulge, focal disc protrusion or extrusion), facet joints (osteophyte, synovial...

Diagnostic studies

Plain films should be taken as an initial study in the evaluation of low back pain. 7. Electrodiagnostic testing. Electromyography and nerve conduction studies are sometimes useful in the evaluation of low back pain. With acute nerve entrapment, results of these studies may be normal, but in chronic cases, they are often abnormal and can be used to corroborate findings from imaging studies and so help to eliminate false-positive results.

In Vivo Application Of Antibodies

In the last 50 years, an increasing number of diseases and patients have been treated with immunoglobulins. Mild adverse reactions (headache, flushing, backache, and nausea) are often associated with fast infusion rates. Only rarely are hematologic, neurologic, or renal adverse effects seen with high doses of IVIG.

Pharmacologic treatment

The mechanism of action of these drugs is not entirely clear, but they are helpful in some patients with acute low back pain. Examples include cyclobenzaprine (10 mg q6h), methocarbamol, and chlorzoxazone. Benzodiazepines such as diazepam may also be used for a limited period (long-term use can decrease the pain threshold).

Postsurgical patients

Exercises for low back pain (see Ch pteL5.6) should not be initiated until the acute phase of recovery has been completed and the patient can move freely without pain (approximately 2 weeks). Patients should be instructed to begin with only three to five repetitions of each exercise and proceed slowly.

Degenerative Disc Disease

Degeneration of the intervetebral lumbar disc is often associated with back pain (17). MRI studies often show marrow changes adjacent to the endplates in patients with degenerative lumbar disc disease (18,19). Modic et al. (19) showed that hyperemic bone marrow changes (type 1 pattern) may progress to conversion of red to yellow marrow changes (type 2 pattern). Lusins et al. compared SPECT bone scintigraphy and lumbar MRI in detecting endplate changes in 48 patients with back pain and MRI disc degenerative changes (20). Thirty-seven patients had increased activity of the endplates seen in SPECT scintigraphy and type I and type II MRI marrow endplate changes. However, 10 patients had abnormal SPECT scintigraphy despite normal MRI marrow endplates. The authors postulated that the increased activity seen with SPECT imaging is attributable to marrow changes and that the marrow changes can be identified by SPECT imaging prior to being seen on MRI.

Postoperative Care

The only postoperative complication that need be looked for is disci-tis. It can occur months after the procedure and manifests as progressively worsening back pain. A normal sedimentation rate virtually excludes the diagnosis, but normal imaging studies do not exclude the diagnosis. In the face of an abnormal sedimentation rate, the disc should be reaspirated to exclude discitis.

Neurological Assessment

Nerve fibers conduct sensory information along a specific pathway. To locate the lesion causing back pain or neuropathy, the pattern of its sensory deficit and its associated motor findings can help. Determine whether the patient is impaired to pain, touch, or position. The patient's ability to distinguish the shape, size, or texture of an object such as a key or paperclip is tested. Test to determine whether there is a loss of the sense of position by moving a digit up or down and asking the patient to indicate the concordant position. The pinprick test is used to elucidate an area of disturbed sensation. The pattern of pain sensation is evaluated by gently applying a sharp pin and asking the patient if the two stimulated areas feel the same. Begin the evaluation in an area where the patient's sensation is considered normal and then proceed to the affected area.

Percutaneous Disc Decompression Chemonucleolysis

After Mixter and Barr established the relationship between intervertebral disc disruption and back pain (39), investigators attempted to find ways to treat this pervasive problem. By far, the most widely used and studied procedure for percutaneous disc decompression is chemonucleolysis. Chemonucleolysis was first per

Selective Nerve Root Blocks

The history of selective nerve root blocks dates back to the turn of the previous century. Shortly after the manufacturing of procaine, Sellhiem described a paravertebral block (60). In 1922, Lawen described the use of procaine to perform a diagnostic paravertebral block, which was the first report of using an anesthetic to perform a diagnostic block (60). In 1930, White performed landmark work using procaine to define pathways of peripheral pain (61). The use of lidocaine for nerve blocks started in the early 1950s after Erdtman synthesized it in 1943 (60). When corticosteroids were synthesized and became available in the 1950s, they were combined with anesthetics to attempt to provide a longer lasting result. It has more recently also been proposed to combine this technique with an epidural injection using a transforaminal approach as a more effective means of treating radicular back pain (62).

Clinical presentation

The classic presentation occurs in a young man between 15 and 40 years old who experiences the insidious onset of intermittent or persistent low back pain and stiffness that is often worse in the morning hours and after prolonged rest. The pain is typically relieved by physical activity. It is usually centered in the lumbosacral spine but may also be present in the buttocks and hips and occasionally radiate into the thighs.

Differential diagnosis

Distinguishing AS from the multitude of other causes of low back pain is challenging. Testing for HLA-B27 is impractical and expensive to perform in all patients complaining of back pain. It should be reserved for patients exhibiting signs and symptoms suggestive, but not diagnostic, of AS. The clinical history, however, may be a sensitive and specific tool in the differential diagnosis. If four or more of the following features are present, the diagnosis of AS should be strongly considered 3. Low back pain lasting longer than 3 months.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) with gadolinium contrast is the preferred method with which to look for suspected metastases in the spine or pelvis because it is a very sensitive and reliable technique to document bony involvement 4 . MRI is especially useful for patients with neurological abnormalities or vertebral body collapse in looking for spinal cord impingement. In the patient with advanced cancer and suspicious new-onset back pain, it may be much more time and cost efficient to go straight to a ''screening'' MRI of the spine first to avoid the usual progression of initial plain radiographs followed by bone scintig-raphy and then a subsequent MRI 10 .

Pathogenesis and Clinical Features

Yellow fever is a hemorrhagic fever with a difference the liver is the major target, with virus replicating in Kupffer cells and massive necrosis of hepato-cytes leading to a decrease in the rate of formation of prothrombin as well as to jaundice. Although most cases are mild, presenting with fever, chills, headache, backache, myalgia, and vomiting, a minority progress (sometimes after a brief remission) to severe jaundice, massive gastrointestinal hemorrhages (hematemesis and rnelena), hypotension, dehydration, proteinuria, and oliguria signaling kidney failure. Mortality from this severe form of the disease is of the order of 20-50 .

Contradictory Evidence

Caragee et al. conducted a prospective study of 8 patients (24 discs) with no history of lower back pain who had undergone posterior iliac bone graft. They found that 50 experienced concordant pain of the usual gluteal area. Thus, the ability of a patient to separate concordant As previously mentioned, Carragee et al. evaluated the incidence of chronic back pain 1 yr after diagnostic dis-cography in a cohort of patients with no prior history of back symptoms. Of the patients with normal psychometric testing, none reported persistent back pain following discography. However, patients with abnormal psycho-motor testing reported a 40 incidence of new low back pain while patients with somatization disorder demonstrated a 66 incidence of new low back pain (41). Finally, Carragee also prospectively studied patients with and without lower back pain after laminotomy and discectomy. From a cohort of240 patients who had undergone single-level discectomy, 20 asymptomatic patients with normal...

Transition From Acute To Chronic Pain Anxiety To Depression

Future fear give way to the frightening awareness that a painful injury or condition may have a permanent effect. Despair and despondency develop as the suffering remains partially unrelieved, and activities become restricted. The seductiveness of seeking, demanding, and receiving help from significant others, including doctors and family, the mildly pleasant and or euphoric effects of medication, or the sedation and induced sleep which avoids pain, can produce a reinforcement contingency for which the pain is a sufficient, and eventually a necessary precursor. Feelings of helplessness lead to depression, guilt, and internalized anger concerning perceived loss of bodily parts or functions, and diminished self-control. Gradually, a time-protracted pattern is established involving helplessness and depression which reinforces pain behavior (Fordyce, 1976 Sternbach, 1968). Pain is sometimes positively reinforced by its pleasant consequences, and sometimes negative consequences are avoided...

Clinical Features

Tropical spastic paraparesis (TSP), otherwise known as HTLV-1 associated myelopathy, is a progressive demyelination of the long motor neuron tracts in the spinal cord. Seen mainly in 20- to 50-year-old women, the affliction starts with lumbar back pain radiating down the legs and progresses to weakness and spastic paralysis of both lower limbs, with dysethesia, urinary frequency or retention, and sometimes visual changes. Unlike multiple sclerosis, there are no remissions.

Surgical Consultation In Vertebroplasty

The management of back pain in the elderly is extremely complex. Vertebroplasty is considered appropriate only for patients with documented, painful vertebral fractures. However, patients often present with pain that may be fully or partially explained by coexisting pathologies such as spinal stenosis or facet disease. In the authors' early experience, the majority of patients were referred from spine surgeons. As such, these early patients had usually been screened, and in some instances, treated for these coexisting pathologies. Continued pain was then readily ascribed to the spinal fracture.

Anesthetic Considerations

Suprapubic prostatectomy can be comfortably performed with the patient under a general or regional anesthetic. With respect to the latter, options include a continuous spinal or epidural anesthetic. Regional anesthesia is advantageous because it is an excellent skeletal and smooth muscle relaxation, airway-related complications (unexpected coughing, gagging, or bucking) can be mostly avoided, and postoperative hemostasis is enhanced in because the patient is more comfortable and tranquil patient (1). Potential disadvantages include a history of documented central or peripheral neurologic deficits after the use of regional anesthetic, potential bleeding tendencies associated with this method, documented chronic low back pain after receiving regional anesthetic, spinal stenosis and or severe degenerative disk disease after regional anesthetic, and associated osseous metastasis (6). In addition, patient acceptance is low. Given the need for prolonged exaggerated lithotomy necessary to...

Intervertebral disc replacement Risk factors for spinal surgery

Pain and instability that remain unresponsive to medical therapies are the primary indications for surgery. However, although osteoarthritis is a prevalent disease in older adults it is often asymptomatic, and other causes of back instability, malalignment and pain are also common in the elderly. Therefore, it is important to fully evaluate patients with these problems to determine whether they relate to osteoarthritis or are due to other underlying disease. Back pain itself is complex, affected not only by biomechanical factors but psychological ones as well. More so than with the hip, the timing and clinical indications for spinal surgeries, and determining which patients will have favorable outcomes, is often unclear. The criteria for diagnosis may be unreliable, and some question whether the outcomes of surgery are adequate to justify the risks and costs 37,38,39 . In the USA during the mid-1990s the estimated annual direct medical cost for low back pain treatments was estimated...

Pain Management Centers

48 million 21.6 million 13.6 million 14 4 billion 65 million 3 billion 100 billion Cancer pain, lower back pain, arthritis, headaches, fibromyalgia For others, chronic pain defined as that which no longer serves a biologically useful function is terribly debilitating and, according to researchers, can actually change the wiring in the brain, spinal cord, and nerve cells by triggering the release of proteins that cause tissue damage. Pain can actually become a disease in itself. Treating it is often a trial-and-error process in which sufferers consult numerous physicians and therapists trying to find the magical cure. Low-back pain is second only to the common cold as the most common cause of illness. Other common causes of pain are migraine headaches, fibromyalgia, arthritis, cancer pain, and that which results from traumatic injuries and degenerative disk disease. Table 4-10 shows the impact and extent of the problem caused by chronic pain.

Treatments for lumbar disc degeneration

While other levels of the spine may present problems, the main reason why patients seek surgical treatment is for low back pain in the lumbar and lumbosacral areas. Painful lumbar disc degeneration is one of the most common indications for surgery. The pain of degenerative joint disease is linked to mobility. While pain is alleviated by surgery to suppress motion by spinal fusion (arthrodesis), it is at the cost of impaired function. Arthrodesis is the currently accepted 'gold standard' surgical treatment for lumbar degenerative disc disease when nonoperative therapies fail. There are a variety of approaches to arthrodesis, including anterior, posterior and posterolateral surgical approaches and the use of spinal fixation devices, with and without pedicle screw instrumentation and interbody fusion cages, and with or without bone graft, cement or bone substitutes to fixate the treatments. The various implants, pedicle screws, and fixation devices are used to remove loose pieces of bone...

Assessment of the safety and effectiveness of intervertebral disc replacement

In addition to the need for better understanding of the overall long-term success of disc implant surgery, we need a better understanding of what population subgroups will likely benefit or fail. Evaluation of patient factors should include age, underlying conditions, prior back surgery, duration of back pain, occupation, activity level, smoking status, body mass index, and severity of disease. These all may have an effect on the survivability of the device and clinical patient outcome. Degenerative disease factors, such as trauma, osteoporosis, osteoarthritis, and cancer, will alter the success rates and rates of complications. It seems likely that the numbers of complications would increase with longer follow-up time, as was seen in total hip arthroplasty 60 . In addition, the type of surgical approach, e.g. percutaneous or open procedure, and number of levels of operated discs have also been shown to be important predictive factors in various spinal treatments. Several studies...

Diagnostic Epidurography and Therapeutic Epidurolysis

Since its introduction in 1985, the Racz procedure (also known as epidurolysis, lysis of adhesions, adhesiolysis, epidural neurolysis, and epidural neuroplasty) has gained widespread acceptance in the pain management community. Early promotion of this technique for delivery of a percutaneous, epidurally administered, lesion-specific dose of steroid for the treatment of low back pain and radiculopathy met with reluctant acceptance at best. Soon published studies verifying the safety and effectiveness of this approach resulted in expanded use and a Current Procedural Terminology (CPT) code paving the way for insurance reimbursement. The therapeutic benefit of a lesion-specific epidural steroid was demonstrated by Winnie et al. in 1972.1 Prior to this, confusion existed over the inconsistent results of the blind epidural (nonradio-logically directed) approach. All too often repeat epidural steroid injection (ESI) procedures performed without fluoroscopic guidance resulted in profoundly...

Hall Drill And Saline Coolant

Skeleton Crossword

During a follow-up visit, she presented with a significant prominence of the right scapula and back pain in the mid and lower back. She denied numbness or tingling of the lower extremities, bowel or bladder problems, chest pain, and shortness of breath. A CT scan of the upper thoracic spine showed a prominent rotatory scoliosis deformity of the right posterior thorax with acute angulation of the ribs. Her deformity is a common consequence of overcorrection of prior spinal fusion surgery, called crank shaft phenomenon.

Transcutaneous electrical nerve stimulator TENS therapy is helpful in some cases

Rehabilitation and exercise Flexibility and strengthening exercise is frequently recommended for patients with low back pain, although objective data supporting benefits are sparse. Nonetheless, there are some basic principles regarding rehabilitation in these patients that should be followed. Physical therapists are helpful in instructing patients in these programs.

Indications and Technique

Posterior Annular Fissure

IDET is indicated in the treatment of chronic, activity-limiting disco-genic low back pain that has been refractory to conservative measures and is generally characterized by 1. Function-limiting low back pain of at least 6 months' duration 2. Back pain greater than leg pain with no true radicular symptoms trajectory of the spinal needle and into the disc (Figure 7.8). The needle is advanced slowly to avoid encountering the traversing root, and if radicular symptoms are elicited, the needle is withdrawn and reoriented to avoid the root. A tactile resistance and gritty crunching is encountered when the needle first enters the annulus, and the fluoro-scope is then repositioned in a posteroanterior (PA) projection. Care should be taken not to advance the needle beyond the disc margins, and if there is any confusion about the position of the needle tip during advancement, the position should be checked fluoroscopically in two orthogonal planes. The patient may report transient localized...

Juvenile Discogenic Disease

Also known as thoracolumbar Scheuermann's disease, this entity affects relatively young patients in their late teens to early 30s with low back pain referable to degenerative disc disease (25). Imaging reveals loss of intervertebral disc height, vertebral endplate irregularities and Schmorl's nodes at the thoracolumbar levels, associated with degenerative disc disease at the lower lumbar levels. Although its etiology is unclear, some have theorized an inherent defect of the disc and endplate leading to these premature degenerative changes (33). Others believe that excessive mechanical forces are to blame, as this disorder was almost an order of magnitude more common in children raised in the country (34,35).

Recommended Technique for Spinal Angiography and Intervention

Vertebral Artery Occlusion Test

Pelvic images of a 50-year-old female who presented with lower back pain and sensory deficit associated with a recurrent giant cell cancer of the sacrum. A preoperative PVA embolization was performed to reduce the intraoperative blood loss. (A) Contrast-enhanced T1-weighted image shows the patchy and irregular enhancement of the sacral body and epidural space (arrows). The nerve roots are encased in the tumor tissue. (B) Pelvic angiogram shows the tumor blood supply from both internal iliac artery branches and the median sacral artery. Figure 16.7. Pelvic images of a 50-year-old female who presented with lower back pain and sensory deficit associated with a recurrent giant cell cancer of the sacrum. A preoperative PVA embolization was performed to reduce the intraoperative blood loss. (A) Contrast-enhanced T1-weighted image shows the patchy and irregular enhancement of the sacral body and epidural space (arrows). The nerve roots are encased in the tumor tissue. (B) Pelvic...

Classic Herniated Nucleus Pulposus HNP

Scan Hernia Nukleus Pulposus

Besides the characterization of the herniation on imaging studies, a number of associated radiographic findings should be considered when one is evaluating patients for APLD. Patients with degenerative facet disease should be carefully evaluated prior to APLD. These patients often have associated back pain that is likely to persist after a successful APLD. A facet nerve block prior to a percutaneous discec- Figure 8.1. (A) Axial MR image showing contained HNP and a small central contained herniation with smooth obtuse margins. This patient would be a good candidate for a percutaneous discectomy. Such individuals often have back pain that can respond only to disc decompression. (B) Sagittal MR image showing contained HNP L4-5 disc herniation is noted. The epicenter of the HNP is at the level of the disc space, and there is no evidence for an extruded fragment. (C) Axial CT scan showing contained HNP. Figure 8.1. (A) Axial MR image showing contained HNP and a small central contained...

Indications For Discography

Low back pain is one of the most common medical problems encountered by healthcare providers. Accordingly, the lumbar spine is the most commonly requested site for discography. For patients whose symptomatology is predominately axial and nonmyelopathic and or nonradicular, imaging may be insufficient or equivocal for determining the nature, location, and extent of symptomatic pathology. Conversely, imaging reveals asymptomatic abnormalities in a substantial proportion of patients (29).

Intramedullary Neoplasms

Dumbbell Lesions Neurofibromatosis

Astrocytomas are the second most common adult spinal cord neoplasms after ependymomas and are the most common intramedullary tumors in children. They occur more commonly in males and typically present in the first three decades of life. Astrocytomas arise more commonly in the cervical cord followed by the thoracic cord, and are unusual in the lumbar region. The vast majority of these lesions are low-grade tumors that may demonstrate multisegmental involvement, cord expansion, and associated syringohydromyelia. They can be seen in patients with neurofibromatosis type I. Back pain and progressive scoliosis are common clinical manifestations. T1W images usually show decreased signal intensity with respect to the cord with some being isointense to the cord. These lesions typically show high T2 signal and heterogeneous enhancement following the administration of gadolinium with areas of cystic changes commonly visualized within the tumor.

Vertebral Hemangiomas

Vertebral Hemangioma Mri

Ing characteristics of hemangiomas presenting with neurological symptoms (cord compression or radiculopathy) 22 of 34 patients (65 ) had holovertebral (body, pedicles, and laminae) involvement, 8 of 34 (23.5 ) had partial body and pedicle posterior element involvement, and 4 of 34 (11.8 ) had involvement of the body only. The majority (25 of 34, or 73.5 ) were women. Young adults formed a large portion of patients presenting with cord compression and or radiculopathy. The majority of lesions (17 of 23 in two series, or 74 ) were in the thoracic spine.24-26 Fox et al. noted that neck or back pain often preceded the neurological symptoms and that thoracic myelopathy was the most common neurological presentation. An additional known risk factor for development of neurological symptoms is pregnancy, with symptoms developing in the third trimester,25 perhaps owing to the role of estrogen and or increased venous pressure due to abdominal disten-tion and pressure of the growing uterus on the...

MJB Stallmeyer and Gregg H Zoarski

Synovial Portion Joint

Sacroiliac (SI) joint dysfunction or arthopathy is thought by many to be a significant source of low back pain and referred lower extremity pain. Bernard and Kirkaldy-Willis1 reported that 22.5 of 1293 patients with low back pain were symptomatic as a result of SI joint disease. Schwarzer et al.,2 using fluoroscopically guided SI joint injections, estimated that the prevalence of SI joint pain in patients with low back pain was between 13 and 30 . From the results of provocation tests and SI joint blocks, Maigne et al.3 concluded that 18 of patients experienced pain attributable to the SI joint. The patterns of pain referral from the SI joint are variable and are thus difficult to distinguish from other causes of low back pain.2,14-16 Presenting symptoms and signs include lower lumbar pain, buttock pain, groin pain, lower abdominal pain, pain radiating to the leg or foot, and focal pain and tenderness over the joint.1,2,14,15,17,18 The complex pain referral patterns are explained by...

Clinical Symptoms And Occurrence Of Complement Activationrelated Pseudoallergy

Common allergic symptoms Anaphylactic shock, angioedema, asthma attack, bronchospasm, chest pain, chill, choking, confusion, conjunctivitis, coughing, cyanosis, death, dermatitis, diaphoresis, dyspnoea, edema, erythema, feeling of imminent death, fever, flush, headache, hypertension, hypotension, hypoxemia, low back pain, lumbar pain, metabolic acidosis, nausea, pruritus, rash, rhinitis, skin eruptions, sneezing, tachypnea, tingling sensations, urticaria, and wheezing Unique symptoms

Intervertebral Discs in Spinal Pain

While incompletely understood, the concept of painful internal disc derangement (the discogenic or discopathic pain mechanism) has progressively gained acceptance as one source of chronic low back pain.2-4 Discogenic pain is typically characterized by axial mechanical midline low back pain, usually exacerbated by sitting or standing for prolonged periods of time. Hallmarks are reports of sitting intolerance with temporary relief when walking. The pain may be aching or stabbing, and there may be some discomfort radiating into the legs, although back pain is typically the more significant complaint. The diagnosis of disco-genic pain is based on classic clinical history (including a pain diagram showing the patient's pain distribution) and pain-provocative discog-raphy with provocation of typical concordant pain symptoms on disc distention. Theories for the exact pathophysiology of the pain mechanism abound, but most revolve around pathological tears of the posterior annulus of the disc...

Abdominal Aortic Aneurysms

Gadolinium Aneurysm

Abdominal aortic aneurysms (AAA) occur in 57 of the population older than 60 years of age. Although most patients with AAA are asymptomatic, they can present with symptoms of mass effect, compression of abdominal organs, or visceral or peripheral emboli originating from the wall of the aneurysm. Rarely, patients present with back pain, which can represent rupture of the aneurysm, a

History And Physical Examination

History and physical examination are key components in the evaluation of patients being considered for percutaneous vertebroplasty. A focused history and examination concentrating on the patient's back pain, mobility level, and medication use (including analgesics, steroids, and osteoporosis antagonists) is recommended. Presenting symptoms, pertinent medical, surgical and allergy histories, a list of current medications, and evidence of failed medical therapy are documented. Use of visual analog scales for determining pain levels, dermatome drawings for pain localization, and standardized questionnaires are helpful for collecting data pre- and post-procedure.

Surgical Complications

The possibility of epidural and intrathecal hemorrhage is frequently mentioned, with the obvious risk of neurological injury. This complication, unfortunately, tends to occur at the time of catheter implant. Pre-operatively, care should be taken to discontinue nonsteroidal anti-inflammatory drugs and reverse any anticoagulation. Signs of a developing hematoma are usually a sudden increase in focal back pain associated with tenderness, progressing numbness and or weakness in the lower extremities, and loss of bowel or bladder control (in the form of retention constipation or incontinence). This clinical presentation warrants immediate imaging with MRI or CT myelogram and emergent neurosurgical intervention if there is neurological deterioration.

The Pathophysiology Of Lumbar Disc Disruption

Lumbar Spinal Fusion

Delamination, or micro-fractures of collagen fibrils leading to mechanical distortion of the annular lamellae and sensitization of nociceptors with release of substance P. In fact, provocative discography triggers substance P release (11). As a result of stimulation of the dorsal root ganglion or direct chemical irritation of the nerve roots, the patient may experience referred pain to the buttocks and legs (39). Patients may present with one of three general types of disc pathologies. The first is the classic leg pain disc caused by disc herniation with nuclear migration through an annular tear and sciatica due to true dural tension. The internally disrupted disc with annular pathology, which produces back pain and variable amounts of buttock and leg pain but no true radiculopathy, causes the back pain disc. The mixed pattern of painful disc disease presents with features of both pathologies caused by small, contained disc herniations and central herniations.

Discitis And Osteomyelitis

Vertebral Osteomyelitis Phlegmon

MRI plays a pivotal role in the evaluation of infectious spondylitis particularly because the diagnosis is often a difficult one to make clinically. Patients with spinal infections present with nonspecific symptoms such as malaise, focal tenderness, radiculopathy, and back pain (38-40). These symptoms may be attributable to other etiologies such as degenerative disorders, spinal stenosis, and neoplasms. In fact, back pain (the most common symptom in patients with infectious spondylitis 40,41 ) is also the second leading cause of physician visits affecting 5 of the population annually (42,43). Physicians therefore often rely on imaging modalities and on laboratory tests such as elevated erythrocyte sedimentation rate (ESR), white blood cell (WBC) count, or C-reactive protein (40). In a group of patients with pyogenic vertebral osteomyelitis evaluated by Caragee, 30 of immunocom-promised and 44 of immunocompetant patients had abnormal WBC counts while 89 of immunocompromised and 100 of...

Mario Muto Cosma Andreula and Marco Leonardi

Low back pain and nerve root pain are among the most common conditions affecting the lumbar spine. Approximately 80 of the population in western countries will experience one or more episodes of low back pain in their lifetime, and 55 will suffer from low back pain associated with a radicular component.1 Back pain is commonly caused by disc disease however, other factors may be responsible for nerve root syndromes, and these should be considered when clinical symptoms fail to match computed tomography (CT) findings.2 We know from the natural history of a herniated disc that clinical symptoms tend to resolve in up to 50 of patients and the disc herni-ation can shrink on follow-up CT or magnetic resonance (MR) scans within 8 or 9 months of the start of back pain.1-3

Abdominal aortic aneurysm AAA

AAA are present in 5 of men aged over 65 years and arc three times commoner in men than women. Patients may present with abdominal and or back pain or an awareness of pulsation. Many patients are asymptomatic until the The diagnosis of ruptured AAA can be difficult because many patients do not exhibit the classical features of abdominal and or back pain, pulsatile abdominal mass and hypotension. The commonest misdiagnosis is renal colic, 'lienal colic' presenting for the first time over the age of 60 years is due to a ruptured AAA until proved otherwise.

N Miscellaneous musculoskeletal problems in patients with neoplasia

Back pain and radiculitis may be secondary to leukemic meningeal involvement or be the initial manifestation of Hodgkin's disease. Shoulder pain with normal findings on shoulder examination may be referred pain caused by infradiaphragmatic, intraabdominal neoplasms. Alternatively, intrathoracic neoplasms (e.g., Pancoast tumor) may extend into the brachial plexus and cause pain in a shoulder with a normal range of motion but evidence of muscle atrophy and loss of deep tendon reflexes.

Abdominal Aortic Dissection

Mra Celiac Artery

Aortic dissection occurs when blood dissects into the media of the aortic wall through an intimal tear. It is generally secondary to hypertension. In young patients with aortic dissection, an underlying process such as Marfan syndrome should be investigated. Dissection originating in the in-frarenal abdominal aorta is very rare and, given the vagueness of presenting symptoms of uncomplicated dissection, diagnosis is very difficult in the early stages. In the absence of a pulsatile abdominal mass, acute uncomplicated aortic dissection should be considered in the differential diagnosis of a sudden onset of abdominal and back pain 22 .

Why Is Coronary Heart Disease More Difficult To Diagnose In Women And Why Is Diagnosis Delayed

Doctors make a diagnosis of angina from the patient's description of her symptoms. Nearly everyone with angina has coronary heart disease. Very rarely, patients with other conditions may have angina but have normal heart arteries. Whereas men with coronary heart disease are more likely to have the typical angina symptoms of chest pain and breathlessness when they exercise, symptoms of angina in women are more often atypical and include back pain, burning in the chest, nausea, and fatigue symptoms that would not usually prompt doctors to consider a heart problem.

Pain Following Spinal Surgery

Patients undergoing laminectomy and laminectomy with fusion have a 10-30 rate of continued or renewed low back pain (38). Causes of low back pain following surgery include degenerative facet or disc disease, recurrence of disc extrusion, infection, spinal stenosis, sacroiliitis, and pseudarthrosis (failure of fusion). SPECT bone scintigraphy is also useful in diagnosing early degenerative facet and disc disease related to changes in biomechanical stress on the spine following fusion surgery. Lusins et al. studied 25 patients with persistent low back pain following lumbar spine surgery and found that more extensive surgery was associated with a greater number of lesions identified in SPECT imaging (42). Patients with single level laminectomy had less extensive facet stress than those with multilevel laminectomy. Patients subjected to laminectomy and fusion had chronic facet stress above and below the fusion mass. This was attributed to transfer of biomechanical stresses to the segments...

Epidemiology of spinal osteoarthritis

Persons with degenerative disease of the spine may have some of the same risk factors that are seen with hip osteoarthritis 41,42 . Although few epidemiologic studies have been conducted to study spinal osteoarthritis perse, major factors appear to be older age, genetic inheritance and trauma 43 . A British cohort study of spinal osteoarthritis in women examined radiological findings of anterior vertebral osteophytosis and disc space narrowing separately and found them to be associated with age, back pain, and radiographic evidence of hip and knee osteoarthritis 44 . Other studies have examined risk factors for low back pain, but not specifically in association with degenerative disc disease 45,46 . Radiographic evidence of degenerative disc disease has a higher prevalence among men than women of the same age 47 . However, other investigators found that vertebral and facet joint osteoarthritis resulted in an increased spinal motion and instability that was more prevalent in women than...

Historical Perspective

Developed in the 1990s as a minimally invasive treatment for chronic discogenic low back pain refractory to conservative measures,3 the IDET technique involves intradiscal delivery of thermal energy to the internal structure of the disc annulus by way of a catheter placed within

Physical Medicine and Rehabilitation

The importance of making an accurate diagnosis cannot be overstated. Frequently, comorbid myofascial dysfunction can become a primary pain source. Patients with back pain can develop severe muscle spasms that then become the primary pain problem. When this occurs, underlying pain generators as well as the myofascial dysfunction need to be treated. Myofascial disease can be corrected with injections (myoneural blocks), stretching exercises, strengthening exercises, application of heat and cold, and correction of gait abnormalities. Other therapies, including the application of electrical stimulation and ultrasound, are commonly used to release muscle spasms.

Complement Activation By Doxil And Other Liposomal Drugs

We suggested that the above MLV-induced hemodynamic and cardiac changes in pigs may represent an amplified model for liposome-induced HSRs in man on the following basis (i) hypotension is one of the major symptoms of acute HSRs in general and of Doxil reactions, in particular (ii) pulmonary hypertension with consequent decrease of left ventricle filling and coronary perfusion can explain the dyspnea with chest and back pain in man, i.e., typical symptoms of HSRs (iii) ECG changes observed in the pig exactly correspond to the cardiac electric abnormalities reported in HSRs to liposomes Ambisome (56) and (iv) the vasoactive dose of Doxil (6-840 mg kg) corresponds to the dose that triggers HSR in humans (17) suggesting that the pigs' sensitivity to Doxil corresponds to that of hypersensitive human subjects.


By far the most common indication for spine imaging is to evaluate for degenerative spondylosis as a cause of acute or chronic neck pain, back pain, or symptoms of radiculopathy. For the purposes of this chapter, the discussion on degenerative disease is limited to the lumbar spine. There are innumerable articles and texts on the subject and yet there is no consensus as to the appropriate workup and management of these pain syndromes. Complicating the matter is the relatively high incidence of spinal imaging abnormalities in healthy volunteers. A well known study by Jensen et al. evaluated 98 asymptomatic Several published studies have evaluated the relative accuracy of MRI, CT, and CT myelography in the diagnosis of lumbar disc herniation. The results demonstrated that the three examinations were essentially equal in diagnostic ability. Jackson et al. prospectively studied 59 symptomatic patients with low back pain and radiculopathy. Each patient was imaged using all three techniques...


Low back pain is an extremely common condition, affecting 80 of persons at some point in their lifetime, which makes this complaint second only to the common cold as a reason for outpatient physician visits. Most episodes of acute low back pain resolve spontaneously, regardless of the type of therapy chosen. However, a small percentage of these acute cases, 5 to 10 in most series, progress to chronic low back pain. It is this latter group of patients that primarily accounts for the enormous amount of disability caused by low back pain, estimated to cost more than 20 billion annually and completely disable more than 2.5 million persons in the United States alone. Epidemiologic studies have established demographic characteristics and risk factors for the development of low back pain. First episodes of low back pain typically occur between the ages of 20 and 40, with a relatively equal sex ratio. Well-established risk factors for the development of low back pain include heavy manual...

Modulating factors

The presence of neurologic symptoms should be specifically sought in patients with low back pain. Their presence not only can help delineate the site of the abnormality but also may prompt more rapid intervention. III. Physical examinations addition to a general examination, patients with low back pain should be examined for specific abnormalities and undergo provocative maneuvers specifically designed to elicit pain in certain syndromes.


Because more than 90 of cases of low back pain are self-limited and resolve spontaneously, any treatment algorithm must account for this and avoid laboratory or imaging studies unless constitutional symptoms, weakness, or neurologic dysfunction suggests an urgent problem.


Numerous conditions, including gout, rheumatoid arthritis (RA), neoplasm, peripheral vascular disease, diabetes mellitus, congenital deformity, and neurologic conditions, can all contribute to foot or ankle dysfunction. Similarly, the altered gait pattern related to foot and ankle dysfunction can contribute to other musculoskeletal complaints, such as low back pain and medial knee pain.


While the use of discography to diagnose spinal pain syndromes has increased, the practice is not free from controversy. Despite reports of its utility in clinical decision making,3 as well as reports of high sensitivity and specificity,15 including one report of 100 sensitivity and specificity in distinguishing symptomatic from asymptomatic patients with back pain,16 discography is innately subjective and thus can never be completely controlled. This aspect of the therapy relates to the use of pain provocation, which must be concordant with presenting symptoms. As Saal17 notes, most pain-provocative or ablative tests used in the diagnosis of spinal conditions are closely related to the physical examination. In the case of nonspecific low back pain created by degenerative lumbar disc disease, the findings from a physical examination are In an attempt to address false positive findings of lumbar discogra-phy, Carragee et al.6 studied eight subjects, with a total of 24 discograms. None...

Past Medical History

The past medical history concerning the spine can be informative. Evaluate details of any relevant medical history that can create back discomfort, including respiratory tract infection (with or without a cough), cardiovascular disease, angina, or gastrointestinal disease (such as regurgitation, reflux, or cholecystitis radiating to the thoracic spine). Pain referred to the back may also originate from urological lesions such as hydronephrosis and renal stones. Review the history of any previous episodes of back pain or neuropathy how many episodes, when they occurred, what was the apparent cause, what was the duration of the discomfort, and did the patient fully recover The history should also review the hip, knee, ankle, and shoulder as well as any trauma or any series of minor trauma. Determine if the patient has sought treatment previously for the pain complained of and the extent of any therapy and the results. Inquire as to whether there is a personal history of cancer. Obtain...

Diagnostic Imaging

Depending on the clinical condition, diagnostic imaging may provide the best clues to the diagnosis. Plain film evaluation of the region of concern provides a good diagnostic tool. Plain film radiography is readily available and cost effective when diagnosing acute low back pain (6).

Disc Herniation

Annulus Vertebrae

Findings of disc disease on MRI examination must be carefully correlated with clinical symptoms (6). Jensen et al. performed lumbar spine MRI on 98 patients without back pain and found a 64 prevalence of either a bulge, protrusion, or extrusion (7). Thirty-eight percent had abnormalities at more than one level. A similar study noted extrusions in 24 of asymptomatic people (8). Furthermore, discogenic pain, caused by a small annular tear with an inflammatory reaction, can often produce severe discomfort. This pain may be present even in patients without significant morphologic changes on imaging (9).

General Assessment

The physical assessment helps the physician reliably document the back pain or neuropathy, which is challenging as several signs and symptoms may overlap. Repeat physical examinations are often necessary to construct the pathway to the offending lesion. Back pain and neuropathy can affect movement and attitude of the gait. Observe the gait pattern and inquire into the use of an ambulatory aid, for example, a cane, corset, wheelchair, or walker. Observe the gait from several projections. With aging, the normal step becomes short (even shuffling), with diminished speed and balance. The legs may be flexed at the hip and knees.


Fritzell H, Hogg O, Wessberg P, et al. Lumbar fusion versus non-surgical treatment for chronic low back pain. Spine 26 2521-2534, 2001. 11. Barnes D, Gatchel RJ, Mayer TG, et al. Changes in MMPI profile levels of chronic low-back-pain patients following successful treatment. J Spinal Dis-ord, 3 353-358, 1990. 20. Parker L, Murrell S, Boden S, Horton W. The outcome of posterolateral fusion in highly selected patients with discogenic low back pain. Spine 21(16) 1909-1917, 1996. 22. Karas R, McIntosh G, Hall H, Wilson L, Melles T. The relationship between nonorganic signs and centralization of symptoms in the prediction of return to work for patients with low back pain. Phys Ther 77(4) 354-360, 1997. 23. Long A. The centralization phenomenon its usefulness as a predictor of outcome in conservative treatment of chronic low back pain. Spine 20(23) 2513-2521, 1995. 24. Sufka A, Hauger B, Trenary M, Hagan A, Lozon R, Martens B. Centralization of low back pain and perceived functional...

Epidural Abscess

Epidural abscess may be catastrophic yet quite inapparent. The patient typically presents with back pain, often thoracic, but with minimal findings on exam of either musculoskeletal or neurologic impairment. Repeat visits to the ED for back pain should raise your suspicion of this disorder. Epidural abscess is a special danger in illicit needle users, precisely the population who may be faking or exaggerating illness to obtain narcotics. Thus, you should be very cautious in dismissing a complaint of severe back pain in needle users. If there is a possibility of epidural abscess, an MRI is usually diagnostic.


As is the case with epidural steroid injections, there is contro-versy concerning the benefit of SNRB. The value is questioned as a diagnostic tool, considering the close proximity of the ventral ramus, the dorsal ramus, and the sinovertebral nerve to the neural foramen. These nerves supply numerous structures that could contribute to the pain complex seen in patients with acute or chronic back pain (Table 1)(8). Care must be taken to block the nerve in a paravertebral position for diagnostic purposes. The frequency of epidural spread with a medial injection will also potentially cloud diagnostic information (9-11). The difficulties associated with the interpretation of pain response were well studied by Wolff et al. (12). They evaluated the effect of a selective nerve root block, by mapping hypesthesia, on pain elicited from nerve stimulation and pain control. They found overlap of two and sometimes three derma-tomal areas when mapping hypes-thesia. Less overlap was present when...


A careful history should be taken to address any recent exposure to an enteric pathogen (a diarrheal illness after travel) or a sexually transmitted pathogen (a new sexual partner). The typical interval between the triggering infection and RS is 1 to 4 weeks, but exceptions earlier or later have been described. A prior history of low back pain or recurrent tendinitis is not uncommon. A history of recent antibiotic therapy is relevant to interpretation of any culture results. Prior episodes of uveitis may not be mentioned by the patient unless specifically sought.

Spinal Tumors

Spinal tumors of children may be found anywhere along the vertebral column. They cause symptoms by compression of the contents of the spinal canal. Localized back pain in a child or adolescent should raise suspicion of a spinal cord tumor, especially if the back pain is worse in the recumbent position and relieved when sitting up. The major signs and symptoms of spinal cord tumors are listed in Table 17-3. Most spinal cord tumors have associated muscle weakness, and the muscle group affected corresponds to the spinal level of the lesions. Back pain (50 of cases) increased in supine position or with Valsalva maneuver Resistance to trunk flexion Paraspinal muscle spasm

Clinical Syndromes

The fever rash arthritis triad of clinical features defines the disease caused by chikungunya, o'nyong-nyong, Ross River, Mayaro, and Sindbis viruses. Indeed, chikungunya and o'nyong nyong are colorful African terms describing the agony of the affected joints' Typically, after a short incubation period of 2-3 days, there is an abrupt onset of fever, chills, myalgia, and severe polv-arthralgia affecting mainly the small joints a rash, generally maculopapular, then appears. Other constitutional symptoms such as nausea, headache, backache,photophobia, and retroorbital pain may also be present but are not so diagnostic. The fever is characteristically high and sometimes of the saddle-back (biphasic) variety in chikungunya, but it is not at all prominent in Ross River virus infection. The arthritis usually resolves in a few weeks but may persist for months or even years in chikungunya and Ross River virus infections.


Several published studies describe clinical trials of magnets. The results of these studies, whether they show an effect or lack of effect for magnets, are typically contested by others. For example, a randomized, double-blind, placebo-controlled cross-over pilot study examined the effect of bipolar magnets on lower back pain 27 . Nineteen men and women with stable lower back pain of duration 6 months and greater were eligible and participated in the study. Real (300 Gauss) and sham magnetic devices which were similar in appearance were applied to the patient's skin, covered with cloth, and then wrapped with a smooth gold-colored foil. Participants underwent 6 hour treatments three times per week for 2 weeks. They rated their pain on a visual analogue scale before and after each treatment. At the end of each week's treatment, subjects responded to the Pain Rating Index of the McGill Pain Questionnaire and were rated for range of motion in the lumbrosacral spine by a clinician. There...

Risk factors

Back pain and fractures are the most characteristic presenting symptoms. Loss of height is a cardinal sign of vertebral OP. More than 60 of vertebral fractures are not symptomatic. Compression fractures are often multiple and most commonly occur in the T-11 to L-2 distribution. Fractures of the wrist (Colles' fracture), hip (femoral neck and intertrochanteric), and pelvis may be the first manifestation of OP. High-turnover OP results from increased bone resorption and occurs at the onset of menopause. Low-turnover OP is caused by decreased osteoblastic bone formation as a consequence of genetics, senility, and antimetabolites.

Storage diseases

Clinically, patients with the disease may be divided into three subgroups. Rheumatologic manifestations may constitute the first symptoms in the neuropathic adult form (type 1) and in the juvenile form (type 3). Acute severe pain (bone crisis) may be accompanied by tenderness, swelling, erythema, and fever, thus resembling osteomyelitis (pseudo-osteomyelitis). Osteonecrosis of the hip and talus have been described. Pathologic fractures of the long bones and low back pain can also occur.

Case History2

A remarkable improvement in pain control occurred some years ago with the presentation of a 50-year-old hotel cook who for years had been trying to convince doctors that there was a physical cause for her severe lower back pain and left-sided sciatica. No specific lesion had been demonstrated after intensive investigations, including lumbar puncture and myelography yet she continued to complain of searing pain and paraesthesiae in one of her lower limbs on a constant basis. Under hypnosis she was asked to


The imaging workup of patients being considered for vertebroplasty can be done in several ways. The simplest type of preprocedural imaging is a plain film study, and is a good starting point in patients who have sudden onset of acute back pain, particularly when it is associated with minor trauma. In osteoporotic female patients with a new compression fracture noted on serial films, focal pain, point tenderness, lack of spinal stenosis or fragment ret-ropulsion, and no history of malignancy, proceeding directly to vertebroplasty is appropriate. Although osteo-porotic compression fractures occur in men, the lifetime risk of a symptomatic fracture is only 5 for males (32). A compression fracture in a male patient with no underlying cause for osteoporosis, for example, steroid use, should raise a flag to the evaluator, and performing magnetic resonance imaging (MRI) to exclude a malignancy is reasonable.


Adverse reactions associated with the administration of the thiazolidinediones include aggravated diabetes mel-litus, upper respiratory infections, sinusitis, headache, pharyngitis, myalgia, diarrhea, and back pain. When used alone, rosiglitazone and pioglitazone rarely cause hypoglycemia. However, patients receiving these drugs in combination with insulin or other oral hypo-glycemics (eg, the sulfonylureas) are at greater risk for hypoglycemia. A reduction in the dosage of insulin or the sulfonylurea may be required to prevent episodes of hypoglycemia.


Back pain from vertebral fractures often lasts between 4 and 6 weeks. It can be associated with ileus, pneumonia, skin decubitus ulcers, and thromboembolic complications. Bed rest and analgesics are recommended until the patient is comfortable (e.g., 1 week). Mobilize and ambulate as tolerated (pool therapy may help). Avoid long-term use of back braces, which ultimately weaken spinal muscles. Calcitonin for treatment of OP and pain. The development of such fractures should prompt an assessment of bone mass and treatment of OP.


Racz Adhesiolysis

And epidurolysis of adhesions are slowly becoming part of our standard of care. While many anesthesiologists still provide epidural steroid injections with a simple hanging drop or loss-of-resistance technique performed without benefit of fluoroscopy, the more sophisticated, fluoroscopically directed, lesion-specific administration of epidural steroid has gained favor. We now have the ability to provide a definitive diagnosis of pathology capable of producing the signs and symptoms of low back pain and radiculopathy, often in the absence of confirmatory radiological evidence. We now understand that abnormalities seen on images produced by magnetic resonance, computed tomography, or myelography do not necessarily cause pain, while normal-appearing structures can be associated with significant disabling pain. A pain physician has the unique opportunity and responsibility to believe a patient's pain complaint while remaining vigilant to any and all findings that might indicate symptom...

Epidural Blood Patch

The risks of EBP are low, but reported complications including sepsis, transient facial paralysis, exacerbation of postdural puncture symptoms, seizure, encephalopathy, arachnoiditis, and transient brachycar-dia. Intrathecal and subdural hematoma have been described. Transient backache or radiculopathy has been reported in patients receiving a lumbar blood patch. Acute meningeal irritative reaction has also been described. Some of these symptoms might be attributed to inadvertent subarachnoid or subdural injections of blood. Image-guided EBP with epidurography is believed to be more accurate and likely to have a lower complication rate than blind EBP. In general, fluoroscopically guided spinal injections are more accurate than blind injections, and the use of image guidance is advocated for EBP if feasible. It has been demonstrated in the literature that blind epidural injections are highly inaccurate. Twenty-five percent of non-image-guided, attempted epidural injections were shown...


Innervation Intervertebral Disc

Tilaginous endplates on the articular surface of the adjacent vertebrae. The annulus itself is composed of two layers, an inner layer that attaches to the cartilaginous endplates, and an outer ligamentous layer that attaches directly to bone of the vertebral bodies. The annulus is loosely attached to the anterior longitudinal ligament but densely adherent to the posterior longitudinal ligament. Annular fibers are thicker anteriorly. The nucleus is a notochordal remnant that is relatively avas-cular in the adult and is not significantly innervated. The role of the nucleus in back pain is believed to be primarily a consequence of mechanical mass effect or chemical effects on local innervated structures. The annulus fibrosus, however, is innervated, most densely along the posterior aspect, and substance P and unmyelinated C fibers have been demonstrated in the annulus, supplied by way of the sinovertebral nerve (Figure 7.2).14-16 Sympathetic fibers are also evident adjacent to the outer...


Back pain is the most common pain complaint resulting in physician office visits. Most back pain resolves spontaneously with conservative treatment, although in some patients, pain persists, and the condition is termed chronic.1 The intervertebral disc has long been thought to be one source of chronic back pain, and in recent years the concept of a disco-genic pain source has become well accepted. Internal disc disruption is now thought to be causative in a large number, if not the majority, of instances of chronic low back pain.2-4 While some patients' symptoms and functional capacity will respond to aggressive conservative measures (rest, epidural steroids, physical therapy), these measures will fail in others. Surgical treatment for these patients, including interbody fusion techniques, has yielded mixed results in management of chronic pain and carries the risk of morbidity at surgery.5-10 In addition, inter-body fusion changes the mechanics of the weight-bearing spinal segment,...

Altered bowel habit

The irritable bowel syndrome is a common cause of altered bowel function in patients under the age of 50 years. The principal symptoms include episodic constipation and diarrhoea associated with abdominal distension, intermittent abdominal pain relieved by defecation and often accompanied by non-specific symptoms including dyspepsia, urinary frequency, backache and tiredness (Table 5.11).

Lumbar Spine

Disc Fragmentation Sagittal Mri

Internal disc disruption (IDD) is a term that was coined in the 1970s to describe pathologic changes of the internal structure of the disc. Internal disc disruption and degeneration involve a physiochemical change in the gly-cosaminoglycans of the NP, which act to bind water over time this water-binding capacity diminishes. Disc degeneration is usually heralded by loss of hydration and thus decreased T2 signal on MRI. However, focal T2 bright areas reflecting annular tears indicate fragmentation of the outer collagenous AF. Hyperintense zone (HIZ) is the term that has been coined to denote this finding on T2-weighted MR images (Fig. 4). In the patient population undergoing MRI for lumbar back pain, this finding may be noted in

Informed Consent

Informed consent can be difficult on labor and delivery, where a patient might first be met when she is in active labor, but it is certainly no less important in this situation. Claims resulting from epidural or spinal anesthetics on pregnant patients often include allegations of back pain or postspinal headaches that are considered within the risks of the procedure. Documenting that this was explained in advance can go a long way toward making these claims defensible. An example of informed consent for an epidural anesthetic would be Infrequently patients get headaches from placement of the epidural. If you do get a headache, there are treatments available. Other uncommon complications are backache, nerve injury, or even death (1).

Clinical studies

A phase I trial involving 23 patients treated with intraventricular topotecan via Ommaya reservoir recommended a Phase II dose of .4 mg in patients 3 years of age. Arachnoiditis characterized by fever, nausea or vomiting, headache, and back pain was the dose limiting side effect 6 23 assessable patients had prolonged disease stabilization or response.23'24 A phase II study in 27 adults with neoplastic meningitis treated with topotecan 0.4 mg intrathecally twice weekly for six weeks, followed by a tapering schedule, produced a median time to progression of six weeks and median overall survival of 13 weeks. Five (16 ) patients cleared CSF of malignant cells, and additional 9 (30 ) showed minor response or stability.25


Enterohepatic System And Urobilinogen

Typical symptoms include itching (pruritus), dark urine and pale stools. Obstruction of the biliary tract is usually extrahepatic in origin and caused by either gallstones or pancreatic carcinoma. The former is suggested by a history of fever, rigors, biliary colic or previous biliary surgery in the latter, chronic persistent back pain, aggravated by recumbency, and palpable enlargement of the gall bladder may occur. Intrahepatic obstruction is most often due to alcohol abuse, drug therapy and primary biliary cirrhosis (a disorder of middle-aged women often preceded by marked pruritus).


Patients typically present with multi-focal symptoms and signs related to different levels of the neuraxis (Table 2).1,3,60 63 Frequent cerebral signs or symptoms include headache, change in mental status, nausea and vomiting, or seizures. Common spinal complaints, e.g. weakness, paresthesias in one or more extremities, back pain, radicular pain, and bladder or bowel dysfunction associated findings include asymmetries of deep tendon reflexes, nuchal rigidity or pain on straight leg raising. The most common cranial nerve complaints are diplopia, facial numbness, hearing loss, and loss of visual acuity.(3)


Methotrexate is detectable in plasma for relatively long periods after IT dosing, but at low concentrations.48 Although systemic toxicity is not usually a problem after an IT dose, some protocols call for administration of a single low oral Leucovorin dose after IT methotrexate. In contrast to systemic toxicity, acute or delayed neurotoxicity is relatively common after IT methotrexate. Chemical arachnoiditis, with headache, photophobia, back pain,


Epidural Space Mri

ESI is commonly used for relief of upper and lower back pain secondary to spinal stenosis, disc herniation with or without radicular pain, and refractory back pain of unknown etiology. ESI may help delay or prevent surgical treatment because many patients receive pain relief that allows them to endure an acute exacerbation of pain. ESI when combined with physical therapy and antiin-flammatory medications can provide satisfactory pain relief in patients who are not surgical candidates.

Patient Preparation

Mra Upper Extremity

In addition to screening for the usual contraindications for MR scanning (e.g. pacemakers) and for the use of Gd-chelate contrast agents (e.g. pregnancy), patients scheduled for a CE MRA examination should also be asked about underlying pulmonary disease and their ability to hold their breath. Intra-abdominal and thoracic CE MRA image quality is markedly improved when performed during a breath hold. Even patients with diminished breath-hold capacity, however, can typically hold their breath for 20-25 seconds if proper coaching is performed in advance and breath holding is optimized by the use of supplemental oxygen and hyperventilation 41 . For multi-station CE MRA examinations (i.e. bolus chase CE MRA) it is also important to know if the patient has any underlying condition that may prevent them from staying still for even short periods of time (e.g. history of Huntington disease or severe back pain), as image subtraction is usually necessary for these exams 42 . Patient...

Supporting Evidence

Hernia Nuclei Pulposi

Also in 1990, Bernard prospectively studied 250 patients with low back pain who underwent lumbar dis In 1991, Simmons et al. performed a study in which 164 patients with low back pain underwent discography and MRI. Discography and MRI results correlated in 80 of the cases. Of abnormal disks, 76 reproduced symptoms on discography (46). In 1996, Schellhas et al. conducted a retrospective study of patients until records of 100 HIZ discs in 63 patients were found. Eighty-seven of the 100 discs tested were found to be concordantly painful. All 87 showed annular tears to the outer third of the annulus fibrosus. Of the 67 non-HIZ discs studied, 64 were nonconcordant. Schellhas concluded that in patients with symptomatic lower back pain, the HIZ is a reliable marker of painful outer annular disruption (13).

Thoracic Spine

The thoracic spine is stabilized by the ribs and has less range of motion than the other segments of the spinal column. Thoracic pain is relatively uncommon. However, it is important from a management perspective because dorsal back pain can be as disabling as cervical and lumbar pain (17). While histological studies of the thoracic discs are currently being reevaluated (18), it has been revealed that branches of the rami communicantes provide innervation circumferentially (17). MRI reveals that a substantial number (11-12.5 ) of asymptomatic degenerative or protruded discs also exist in the thoracic spine (19). However, anatomical changes on imaging studies do not necessarily equate with pain generation. In one investigation, approximately one quarter of the discs injected provoked a pain response that did not match MRI findings or morphologic findings at discography (20). One case series on thoracic discography concluded that useful information is obtained for treatment planning...

Epidural Injections

Epidural injections have been used in the management of neck and back pain for almost 100 yr, although they still remain quite controversial. The first reported epidural injection for pain management was in 1901 in Paris. M. A. Sicard injected cocaine for the treatment of sciatica (26). The description of the paramidline approach to the lumbar epidural space was proposed by Pag s in 1921 (27). Pag s' technique used the tactile feedback from the needles touching and passing through the ligamentum flavum as a means of identifying the epidural space. Confirmation of needle placement in the epidural space was based on absence of free flow of spinal fluid from the needle and the lack of resistance to injection of local anesthetic (27). This approach was technically demanding and was associated with a significant failure rate.


Sacral stress fractures may present as low back or buttock pain, mimicking disk disease, sciatica, or sacroiliac joint pathology. These fractures more commonly affect the female runner there are reports of adolescent female runners who had low back pain subsequently being diagnosed with sacral stress fractures


Although numerous studies have argued the efficacy of epidural steroid injections,10,12-21 many of these trials are flawed in design. Unfortunately, double-blind controlled and randomized studies are difficult to perform in the clinical area. Despite this, there are a number of investigations that provide convincing evidence that epidural steroid injections are effective. Coomes and coworkers showed that epidural injections with anesthetic agents are more effective than bed rest for the treatment of low back pain.16 Burn and Langdon showed improvement in two thirds of the patients at 6 months (complete resolution of symptoms or significantly decreased pain).14 These investigators stratified patients based on age and duration of symptoms and found the best responses when symptoms were less than one year in duration and patient age was greater than 40 years. Heyse-Moore reported 120 consecutive patients who received epidural steroid injections with local anesthetic and found an overall...

Postprocedure Care

Immediately following the procedure patients are transferred to a stretcher and remain supine for 1 h. Subsequently they are slowly mobilized and discharged. Patients are instructed that they may feel discomfort of a different character than the fracture pain previously experienced, which we ascribe to mild trauma from needle placement. A small bandage is placed over the derma-totomy site. Patients are encouraged to use nonsteroidal antiinflammatory pain medications as needed, but to limit narcotic use so efficacy can be determined. Prior to discharge patients are evaluated for new chest or back pain, new neurological symptoms, or other complaints that may indi-cate a complication. Most significant complications are due to inappropriate cement deposition, and the patient will quickly become symptomatic. Early recognition is key so that treatment can be instituted, and suspected complications should be considered an emergency. Imme Telephone follow-up 1-3 d after vertebroplasty is...


The manifestation of back pain and neuropathy is complex and varies in individual patients. This chapter serves as a guide for the clinician when evaluating patients with such symptoms. The patient's history, physical examination, and diagnostic tools discussed will help the clinician identify the cause of the pain or neurological deficit, distinguish referred from local symptoms, and differentiate a neuropathy from pain of musculosketal origin. Treatment can be initiated after a thorough clinical evaluation.


Obtain the list of any medications being taken. The patient being screened for back pain or neuropathy is commonly taking analgesic medication. Determine what medications the patient has tried and found to be effective and ineffective in treating the pain. The assessment should include information relating to the dose and schedule of any medication. Commonly asked questions include does the medication reduce or eliminate the pain How often and when is the medication taken Are any medications used for problems with sleeping Inquire about the use of herbal therapy. Although it is a sensitive topic, you must ask the patient about recreational drug use.

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Tired Having Back Pains All The Time, But You Choose To Ignore It? Every year millions of people see their lives and favorite activities limited by back pain. They forego activities they once loved because of it and in some cases may not even be able to perform their job as well as they once could due to back pain.

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