EULAR evidence-based recommendations for the management of fibromyalgia syndrome

OBJECTIVE

To develop evidence-based recommendations for the management of fibromyalgia syndrome.

METHODS

A multidisciplinary task force was formed representing 11 European countries. The design of the study, including search strategy, participants, interventions, outcome measures, data collection and analytical method, was defined at the outset. A systematic review was undertaken with the keywords "fibromyalgia", "treatment or management" and "trial". Studies were excluded if they did not utilise the American College of Rheumatology classification criteria, were not clinical trials, or included patients with chronic fatigue syndrome or myalgic encephalomyelitis. Primary outcome measures were change in pain assessed by visual analogue scale and fibromyalgia impact questionnaire. The quality of the studies was categorised based on randomisation, blinding and allocation concealment. Only the highest quality studies were used to base recommendations on. When there was insufficient evidence from the literature, a Delphi process was used to provide basis for recommendation.

RESULTS

146 studies were eligible for the review. 39 pharmacological intervention studies and 59 non-pharmacological were included in the final recommendation summary tables once those of a lower quality or with insufficient data were separated. The categories of treatment identified were antidepressants, analgesics, and "other pharmacological" and exercise, cognitive behavioural therapy, education, dietary interventions and "other non-pharmacological". In many studies sample size was small and the quality of the study was insufficient for strong recommendations to be made.

CONCLUSIONS

Nine recommendations for the management of fibromyalgia syndrome were developed using a systematic review and expert consensus.

Predictive factors of efficacy of periradicular corticosteroid injections for lumbar radiculopathy

BACKGROUND AND PURPOSE

Steroid periradicular infiltration is a common nonsurgical sciatic pain treatment of inconsistent efficacy. The purpose of this study was to identify factors for predicting the efficacy or failure of this procedure.

METHODS

Two hundred twenty-nine patients with lumbar radiculopathy were prospectively followed up at 2 weeks and 1 year after percutaneous periradicular steroid infiltration. The intensity of radicular pain was scored on the visual analog scale (VAS). Pain relief was classified as "excellent" when the pain was completely resolved or had diminished by 75% or more, "good" for a diminution of 50% to 74%, "fair" for a diminution of 25% to 49%, or "poor" for a diminution of less than 25% or an increase in pain.

RESULTS

The mean VAS scores were 6.5 (range, 3.1-9.5) before and 4.2 (range, 0-9.5) 2 weeks after the procedure. Pain relief was graded as excellent in 45 patients (19.7%), good in 48 patients (21%), fair in 45 patients (19.7%), and poor in 91 patients (39.7%). Cause of pain, conflict location, and pain intensity were not predictive factors of radicular pain relief, whereas the symptom duration before the procedure was highly correlated with the pain relief outcome. Patients with excellent results 2 weeks after the procedure had a mean duration of symptoms of 3.04 months (SD 3.28) versus 7.96 months (DS 9.04) in the group with poor pain relief.

CONCLUSIONS

Periradicular infiltration is a simple, safe, and effective nonsurgical procedure that should be performed quite early in the course of the illness to provide radicular pain relief, because corticosteroid infiltration is less beneficial for patients with more chronic radicular pain.

Awareness and knowledge of fibromyalgia among French rheumatologists and general practitioners

OBJECTIVES

Fibromyalgia is a chronic disorder characterized by widespread musculoskeletal pain and fatigue. Its prevalence is estimated to be at 3.4% in women and 0.5% in men. It is a major cause of morbidity. Our objective was to evaluate, using a self-questionnaire sent by mail, the level of knowledge of French physicians, general practitioners, and rheumatologists on fibromyalgia and to analyse their therapeutic approach.

METHODS

The demographic characteristics of a sample of general practitioners and rheumatologists were compared to those of the overall data available. This comparison demonstrated the good representativeness of our sample.

RESULTS

Fibromyalgia was considered as a disease by 23% of rheumatologists and 33% of general practitioners. While on average, each rheumatologist followed 30 fibromyalgia patients, each general practitioner followed 6.1 patients (i.e., 2 to 5% of their practice's patient base). Among rheumatologists, 6.4% made no distinction between this disease and depression vs. 13.1% of general practitioners. The diagnosis of fibromyalgia was made based on tenderness that occurs in precise, localized areas of the body (trigger points) by 94% of rheumatologists and 79.1% of general practitioners. Of general practitioners and rheumatologists, 93.7% and 73.7% respectively, have not received any medical school training on fibromyalgia or chronic fatigue syndrome.

CONCLUSION

Given the lack of medical school training and continuing professional education concerning fibromyalgia (rare use of pain rating scales, confusion in the classification of rheumatic diseases), there is an urgent need to initiate an explicit teaching effort on chronic pain, and on fibromyalgia in particular.

Efficacy of transforaminal versus interspinous corticosteroid injectionin discal radiculalgia ? a prospective, randomised, double-blind study

A prospective, randomised, double-blind study was carried out to compare the respective efficacies of transforaminal and interspinous epidural corticosteroid injections in discal radiculalgia. Thirty-one patients (18 females, 13 males) with discal radicular pain of less than 3 months' duration were consecutively randomised to receive either radio-guided transforaminal or blindly performed interspinous epidural corticosteroid injections. Post-treatment outcome was evaluated clinically at 6 and 30 days, and then at 6 months, but only by mailed questionnaire. At day 6, the between-group difference was significantly in favour of the transforaminal group with respect to Schober's index, finger-to-floor distance, daily activities, and work and leisure activities on the Dallas pain scale. At day 30, pain relief was significantly better in the transforaminal group. At month 6, answers to the mailed questionnaire still showed significantly better results for transforaminal injection concerning pain, daily activities, work and leisure activities and anxiety and depression, with a decline in the Roland-Morris score. In recent discal radiculalgia, the efficacy of radio-guided transforaminal epidural corticosteroid injections was higher than that obtained with blindly-performed interspinous injections.

Metastatic pudendal nerve compression presenting as atypical sciatica

A rare case of Alcock's syndrome caused by tumoral compression of the pudendal nerve is reported. Spine surgeons must be aware of the possibility of Alcock's syndrome in patients presenting with atypical sciatica.

Normal vertebral body dimensions: a new measurement method using MRI

Much clinical research on osteoporosis is aimed at documenting a reduction in vertebral fracture rates, but there is considerable disagreement about defining normality. Most methods for measuring vertebral body dimensions use lateral radiographs. In the present paper, we investigate the reliability of magnetic resonance imaging (MRI) for normal reference determination. A validation study was performed on a cadaver by comparing vertebral body volume measured both with MRI (sagittal acquisition in T1 weighted sequence) and with immersion. MRI was then performed with the same protocol from T4 to L5 in a standard population of 80 women with no history of vertebral fractures. Then all vertebral measurements were standardized relative to each other, and means and standard deviations were calculated using a statistical fitting procedure derived from volume and medial area. The validation study confirmed the reproducibility and accuracy of MRI (intraclass correlation coefficient 0.95). There was a strong correlation between volume and medial area of vertebral bodies (Pearson correlation coefficient 0.95) and a constant relationship between the medial area of vertebral bodies for each subject (coefficient of variation 5.6%). The variations in vertebral body dimensions will allow comparison with pathologic vertebral fractures in further studies. This could be useful for monitoring osteoporosis treatments.

[Association of Kaposi sarcoma--multiple myeloma. A new case]

INTRODUCTION

Kaposi's disease is an angiogenic multifocal cancer process that has several forms, namely Mediterranean, African, HIV-associated, and secondary to a preexisting immunodepressive state (hematological disorder, corticosteroid therapy, immunodepressive treatment). Whatever its form, Kaposi's sarcoma is probably associated with a chronic viral human herpes type 8 infection (HHV8).

EXEGESIS

This virus has been implicated in the pathogenesis of multiple myeloma (17 cases recorded to date). In the present study, a further case of Kaposi's sarcoma associated with multiple myeloma has been reported. However, Epstein-Barr virus, cytomegalovirus, hepatitis B and C, HIV and HHV8 serologies were negative. Radiotherapy on the lower limbs was initiated.

CONCLUSION

It is concluded that HHV8 does not appear to play a pathogenic role in cases of multiple myeloma, given the rarity of the association between Kaposi's sarcoma/multiple myeloma/HHV8.

Motor cortical dysfunction disclosed by single and double magnetic stimulation in patients with fibromyalgia

OBJECTIVE

To investigate the motor cortex by single and double magnetic stimulation, in patients with fibromyalgia.

METHODS

Thirteen patients with fibromyalgia and 13 age-matched healthy subjects were examined. We evaluated, in both limbs, motor evoked potential (MEP) latency and amplitude and the MCA/MPA ratio, i.e. MEP cortical amplitude (MCA) /maximal peripheral amplitude of the M response (MPA), the central conduction time (TCC) and the length of the silent period (SP). With double magnetic stimulation, different time intervals between shocks were used: with delays between shocks of 4, 25, 55 and 85 ms, the intensities of the conditioning shock were 80% the relaxed threshold. With delays between shocks of 55, 85, 100, 155, 200, 255 and 355 ms, the intensities of the conditioning shocks were set at 150% the relaxed threshold. In all cases, the intensity of the test shock was 150% the relaxed threshold. The results were also compared with those obtained in 5 women affected by rheumatoid arthritis (RA).

RESULTS

As compared to control, the cortical relaxed threshold was enhanced on both sides and limbs (P<0.05). The cortical silent period recorded with single magnetic stimulation was reduced in the upper limbs (P = 2.7x10(-11)) and lower limbs (both sides P = 3.6x10(-5)). The other parameters investigated were normal. With double magnetic stimulation, facilitatory phenomena were absent in fibromyalgic patients and the inhibitory responses recorded with a delay of 155 ms were reduced (P = 0.0052). No significant differences were noted between FM and RA patients.

CONCLUSION

This study demonstrated motor cortical dysfunction in patients with fibromyalgia involving excitatory and inhibitory mechanisms. This indicates motor cortical involvement and supports the hypothesis of aberrant central pain mechanisms. The absence of differences between FM and RA suggest that the lesions were not specific and could be related to chronic pain disorders within the central nervous system.

Acute osteoporotic vertebral collapse: open study on percutaneous injection of acrylic surgical cement in 20 patients

OBJECTIVE

The aim of this study was to determine the efficacy of percutaneous vertebroplasty in treating painful spinal osteoporotic collapse.

SUBJECTS AND METHODS

Twenty-three cases of vertebral collapse were evaluated with CT and MR imaging to determine osteoporotic origin and recent evolution. Percutaneous vertebroplasties were performed using CT guidance. The 20 patients included in the study (17 women, 3 men; 62-92 years old) had acute pain of less than 1 month's duration that hindered ambulation and required treatment with narcotic drugs. They underwent this procedure for analgesic purposes. The analogic visual scale of Huskisson was used for pain when scoring assessment.

RESULTS

In 15 patients (75%), pain relief was complete within 24 hr after injection. Analgesic administration was stopped in 14 patients. Mild pain persisted in three (15%) of the remaining five patients. In one other patient (5%), crural pain was observed with cement leakage in the psoas muscle. In the fifth patient (5%), pain recurred after the patient was lifted. The pain was related to a new acute collapse of an adjacent vertebrae.

CONCLUSION

Vertebroplasty for the treatment of osteoporotic vertebral collapse is a minimally invasive procedure that provides immediate pain relief and enables the patient to become quickly mobile.

Fibromyalgia as a national issue: the French example

Fibromyalgia has been known by French rheumatologists for more than 15 years. However, only recently have teaching and basic, clinical and epidemiological research been developed on this topic in France. Management of the fibromyalgia patient should benefit from this recent evolution, all the more so since the French government took action to facilitate the medical treatment of chronic pain and to support the development of algology in France.

Inhospital management of common lumbosciatic syndrome. An opinion survey among French rheumatologists

To determine which treatments are most commonly offered to patients younger than 70 years of age admitted for uncomplicated lumbosciatica suggestive of disk herniation, we sent a 43-item questionnaire to 106 rheumatology departments in France. The questionnaire collected information on hospital stay duration, modalities of rest, drug treatments, local glucocorticoid injections, physical treatments, sick leave duration and advice given to the patients. The response rate was 77% (84 questionnaires). Substantial variations were found across departments. Hospital stay duration ranged from five to 20 days and nonsteroidal antiinflammatory drug treatment duration from five to 30 days. Local glucocorticoid therapy was given as one to four injections at intervals of two to seven days. Spinal traction was used in 38% and a corset in 50% of study centers. Neither was there any consensus regarding immediate or delayed physiotherapy. Most respondents recommended bedrest for no longer than 15 days, a nonsteroidal antiinflammatory drug, a level I or II analgesic, local glucocorticoid injections and, in the event of persistent pain at the end of the hospital stay, a lumbar corset.

Validation of the French version of the Dallas Pain Questionnaire in chronic low back pain patients

OBJECTIVES

To translate and to validate the metrological properties of the Dallas Pain Questionnaire, an instrument designed to evaluate the impact of low back pain on four aspects of patients' lives: daily activities, work and leisure activities, anxiety/depression and social interest.

METHODS

The Dallas Pain Questionnaire, originally in English, was translated into French. The metrological properties of the French version were investigated in a cohort of 59 patients with chronic low back pain due to degenerative disk disease. Duration of the pain was between three and 24 months. Treatment consisted of nonsteroidal antiinflammatory drugs and/or analgesics, local corticosteroid injections and a plaster lumbar corset. Patients were evaluated at baseline, after ten days (under the same treatment), and at completion of the treatment.

RESULTS

Results were reproducible for all four areas of the questionnaire (CCI > 0.75). Internal structural validity was satisfactory for the four areas (Cronbach alpha test = 0.89 to 0.91). At baseline, the pain score on a visual analog scale was significantly correlated with the Dallas scores for daily activities, anxiety/depression and social interest (external structural validity). The daily activities, work/leisure and anxiety/depression scores were sensitive to change (P < 0.001, P < 0.001, and P = 0.003, respectively), whereas the social interest score was not (P = 0.11).

CONCLUSION

The French version of the Dallas Pain Questionnaire is valid, reproducible, and sensitive to change in chronic low back pain patients.

Tophaceous gout of the navicular bone as a cause of medial inflammatory tumor of the foot

A case of tophaceous gout of the navicular bone in a 24-year-old woman is reported. Emphasis is placed on the conditions that might have been precipitating, i.e., anorexia nervosa and alcoholism, and the mechanisms by which increased uric acid level may be explained. The main radiographic patterns of tophaceous gout of the foot are recalled to avoid unnecessary surgery in future cases.

Efficacy and safety of avocado/soybean unsaponifiables in the treatment of symptomatic osteoarthritis of the knee and hip. A prospective, multicenter, three-month, randomized, double-blind, placebo-controlled trial

One of the objectives of symptomatic slow-acting drugs for osteoarthritis is to reduce the need for drugs with a less favorable safety profile, mainly analgesics and nonsteroidal antiinflammatory drugs (NSAIDs). We conducted a three-month, prospective, randomized, double-blind, placebo-controlled, parallel-group trial to evaluate the efficacy of avocado/soybean unsaponifiables in terms of NSAID use reduction. Patients with primary femorotibial or hip osteoarthritis (OA) (ACR criteria and Kellgren-Lawrence radiological stage IB, II, or III) of at least six months' duration with regular pain for more than three months requiring therapy with NSAID (visual analog scale score > or = 25 mm and Lequesne's index on therapy > or = 4) were given one capsule per day of avocado/soybean unsaponifiables or a placebo for three months. During the first 45 days, patients in both groups were also given one of seven predefined NSAIDs. The primary efficacy criteria was the rate of patients taking back a NSAID and the delay before re-intake. Secondary efficacy criteria were the total dose of NSAID, overall ratings by the patient and by the physician, the visual analog scale pain score and the functional index. Of the 164 included patients, 163 were evaluable, 80 in the active drug group and 83 in the placebo group. Mean age was 62.9 +/- 8.8 years. The diagnosis was femorotibial OA in 101 patients and hip OA in 62. Data were collected on day 45 in 153 patients (77 on the active drug and 76 on the placebo). The number of patients who took back NSAID therapy was significantly smaller in the group treated by avocado/soybean unsaponifiables (33; 43.4%) than in the placebo group (53; 69.7%) (P < 0.001). Also, beyond day 54, the time spent off NSAID therapy was shorter in the placebo group. The functional index showed a significantly greater improvement in the active drug group (-2.3 +/- 2.6) than in the placebo group (-1.0 +/- 2.6) (P < 0.01). Pain scores over time were similar in the two groups. Overall patient ratings were significantly better in the active drug group (P < 0.01). Safety was oggd in both groups. After six weeks, avocado/soybean unsaponifiables reduced the need for NSAID in patients with lower limb OA.

Postoperative shoulder rotators strength in stages II and III impingement syndrome

In healthy subjects, the shoulder internal rotator muscle strength overrides the external rotators. This has been confirmed in different isokinetic studies showing the ratio of the relative strengths of the internal to external rotators to range from 1.3 to 1.5 points, depending on the study. The authors previously reported a decrease in the relative strength ratio of the internal to external rotators to close to 1 in patients suffering from Neer's impingement syndrome. The aim of the present study was to assess, long after surgery (mean, 44.5 months), the isokinetic strength performance of shoulder rotator muscles in 72 patients who had had operative treatment for chronic subacromial impingement using anterior acromioplasty, sometimes combined with cuff repair surgery. Tests were conducted with a Biodex Multi-Joint System in the plane of the scapula and in 45 degrees abduction at 60 degrees and 180 degrees per second. Peak torque and average power were calculated. The mean ratios of relative strengths of the internal to external rotators ranged from 1.3 to 1.6 points depending on the parameter studied and the test speed. These results indicate that surgery restores normal muscular balance between shoulder rotator muscles affected by the impingement syndrome.

Diagnostic value of clinical tests for shoulder impingement syndrome

Results of three clinical tests for detecting shoulder impingement syndrome (Neer's, Hawkins', and Yocum's tests) and four tests for determining the location of the rotator cuff lesion (Jobe's test [supraspinatus], Patte's test [infraspinatus], lift-off test [subscapularis], and palm-up test [long head of the biceps brachii]) were compared to intraoperatively observed anatomic lesions in 55 consecutive patients who had surgery for Neer's syndrome. For Jobe's and Patte's tests, both pain (denoting tendinitis) and functional impairment (denoting tendon rupture) were evaluated. All clinical tests were done by the same examiner and all surgical procedures (acromioplasty with or without rotator cuff repair) by the same surgeon. The location and extent of the lesions (size of the tear in the 34 patients with rotator cuff defects) were determined intraoperatively. The sensitivity, specificity, and positive and negative predictive values of each test were calculated. Sensitivity was satisfactory but specificity was poor, in particular for determining the location and type of rotator cuff lesions. The severity of functional impairment during Jobe's and Patte's maneuvers was not correlated with the size of the tear.

Tophaceous gout of the patella with primary hyperparathyroidism

The case of an 81-year-old woman with persistent post-traumatic pain of the knee linked to tophaceous gout of the patella is presented. This gout was associated with adenomatous primary hyperparathyroidism. The relationship between hyperuricemia, hyperparathyroidism and chronic renal failure is discussed.

Conversion of endogenous arachidonic acid to 5,15-diHETE and lipoxins by polymorphonuclear cells from patients with rheumatoid arthritis

The conversion of endogenous arachidonic acid (AA) by polymorphonuclear cells (PMN) from patients with rheumatoid arthritis (RA) was studied before (D0) and one day (D1) after antiinflammatory drug therapy. The biosynthesis of 5,15-diHETE and lipoxins (LXS), were investigated ex vivo, after PMN stimulation by ionophore A23187 without exogenous addition of 15-HETE. The eicosanoids were resolved by RP-HPLC and simultaneously detected at 246 and 302 nm respectively. Large amounts of 5,15-diHETE (50 to 400 ng/10(7) PMN) and significant levels of LXS (from 2 to 20 ng/10(7) PMN) were produced with individual differences between donors. Metabolite levels varied between patients but this work showed for the first time a linear relationship between the amounts of 5,15-diHETE and LXS. Moreover LXS production after treatment may be related to long-term clinical improvement of patients.

Multiple psoas abscesses after posterior spinal fusion

STUDY DESIGN

A case of multiple psoas abscesses after Dove lumbar spine fixation is reported.

OBJECTIVES

To review the diagnosis and treatment of deep infection after internal spinal fixation.

METHODS

The possibility of septic complications after spinal surgery that may present with a degenerative pattern is examined. The clinical and computed tomographic findings of a psoas abscess are recalled.

RESULTS

Surgical drainage of the purulent collection was performed along with prolonged parenteral antibiotic treatment.

CONCLUSION

Infection should be considered as a cause of recurrence of pain after internal fixation of the lumbar spine.

Enhancement of leukotriene A4 biosynthesis in neutrophils from patients with rheumatoid arthritis after a single glucocorticoid dose

Human blood polymorphonuclear cells (PMN) from seven patients with active rheumatoid arthritis (RA) were compared for their capacities to produce leukotrienes ex vivo before (D0) and 24 hr (D1) after glucocorticoid pulse therapy. The present study shows for the first time that endogenous arachidonic acid metabolism via 5-lipoxygenase pathway is significantly increased after glucocorticoid administration, leading to increased generation of the unstable precursor leukotriene A4 (LTA4) followed by predominant non-enzymatic LTA4 opening and leukotriene B4 (LTB4) omega-hydroxylation pathway. These results are unexpected since usually glucocorticoids are usually thought to decrease inflammatory mediator biosynthesis and, moreover, they work to the detriment of the clinical improvement of the patient. The results are discussed in terms of product inactivation and cellular cooperation with monocytes and endothelial cells.

Are classification criteria for spondylarthropathy useful as diagnostic criteria?

The authors used data from a study conducted under the auspices of the Société Française de Rhumatologie to evaluate the sensitivity and specificity of the individual items of two sets of criteria for spondylarthropathy. The study included 124 patients with spondylarthropathy and 1,964 controls. They found that the spondylarthropathy criteria with the highest sensitivities and specificities were useful not only for classifying patients but also for assisting in the diagnosis of spondylarthropathy.

Isokinetic evaluation of rotational strength in normal shoulders and shoulders with impingement syndrome

The purpose of this study was to determine whether imbalance of the internal and external rotator musculature of the shoulder were etiological factors implicated in impingement syndrome. Shoulder torque measurements were obtained from 15 asymptomatic volunteers and 30 patients with chronic impingement syndrome, 15 of whom were evaluated after arthroscopic anterior acromioplasty. Isokinetic strength was assessed using the Biodex system in a modified position (in the plane of the scapula and in 45 degrees abduction) with test speeds of 60 degrees and 180 degrees per second. Internal and external rotator strength values and ratios were calculated for both peak torque and average power. Shoulder rotational strength values and the internal rotator/external rotator ratio were significantly higher in the dominant and nondominant control group shoulders than in the involved and uninvolved impingement shoulders for operated on and nonoperated on patients. These data demonstrate that primary change in the normal internal rotator/external rotator ratio of the shoulder is an etiological factor implicated in impingement syndrome not modified by anterior acromioplasty.

[Inferior glenohumeral subluxation: an indirect sign of sepsis of the shoulder]

Drooping shoulder is a roentgenographic abnormality consisting in a discontinuity in the scapulo-humeral arch due to inferior subdislocation of the humeral head. Drooping shoulder is commonly seen in patients with injuries to the shoulder or neurological loss. Two cases of drooping shoulder due to staphylococcal arthritis (after local corticosteroid injections) are reported herein. The mechanism of the downward humeral displacement in septic arthritis is discussed. The other causes of drooping shoulder are reviewed. Precautions needed to avoid increasing the displacement during rehabilitation therapy are outlined.

Sacral insufficiency fractures presenting as acute low-back pain. Biomechanical aspects

Sacral insufficiency fractures are an often unsuspected cause of low-back pain in elderly women with osteopenia who have sustained unknown or only minimal trauma. The authors describe 10 cases of spontaneous sacral insufficiency fractures, confirmed by computed tomography, characterized by the onset of acute low-back pain. Differential clinical and radiographic diagnosis of these fractures is often difficult. Recognition of the characteristic scintigraphic patterns in sacral fractures, which are frequent in osteopenic patients, could avoid mistaken diagnoses and unnecessary tests or treatment. One of the striking feature of these sacral fractures is their invariable location. The fractures extend vertically in the sacral alae, parallel to the sacroiliac joints. They are located just lateral to the margins of the lumbar spine. This distribution suggests that such fractures could be partially caused by weight-bearing transmitted through the spine.

[Cauda equina syndrome disclosing adenocarcinoma of the ethmoid]

Cauda equina metastases have been exceptionally described in sinusal neoplasms. MRI with gadolinium injection show up the primitive lesion and its neurologic extension. We report a case of cauda equina syndrome in which, only MRI, had show up intradural metastases and localised the ethmoïd sinus carcinoma.

[Determination of the instantaneous center of rotation of the shoulder using the ELITE system. Application to the study of normal and pathological abduction]

The authors determined the in vivo displacement of the instantaneous center of rotation (ICR) of the shoulder from data supplied by an optoelectronic system (ELITE System) which uses a specifically designed software program to achieve 3-dimensional analysis of abduction. The study involved 10 control subjects and 20 patients suffering from a periarticular disorder of the shoulder capsule retraction in 10 cases and rotator cuff tears before and after rehabilitation in 10 cases. This method provides an objective assessment of humeral head misalignment in relation to the glenoid cavity induced by the periarticular shoulder disorder and of the realignment achieved through rehabilitation. The proposed ICR calculation technique is entirely harmless for the patient in (particular because it requires no radiation analysis).

Measurement of the bone mineral density of the os calcis as an indication of vertebral fracture in women with lumbar osteoarthritis

In women with lumbar osteoarthritis, measurement of the os calcis bone mineral density (BMD) using dual-energy X-ray absorptiometry (DEXA) as an indication of vertebral fracture was evaluated. The in vivo precision of the method was 1.28%. Age- and sex-matched control curves were evaluated using a control of 193 females. The correlation between spine BMD and os calcis BMD was significant (r = 0.65, p << 0.001). For the osteoporotic women without osteoarthritis (n = 34), there was no significant difference in the spine and the os calcis Z-scores (-1.99SD and -1.83SD respectively). Whereas for osteoporotic women with osteoarthritis (n = 30) the spine Z-score was -0.49SD the os calcis Z-score was -1.92SD. The difference was significant (p < 0.001). Receiver operating characteristic (ROC) curves demonstrate the superiority of the os calcis as a measurement site over the lumbar spine, in correlation with existing crush fractures in the presence of osteoarthritis. It is concluded that when lumbar osteoarthritis occurs measurement of the os calcis BMD using DEXA is clinically useful for the estimation of bone mass.

[Meningoencephalitis disclosing Behçet disease. Value of nuclear magnetic resonance imaging]

A meningoencephalitis Behçet's disease revealing is reported. Magnetic resonance imaging is more sensitive than computerized tomography in detecting encephalitic lesions. However, no specific pattern may be retained. This exploration is non invasive and can be used to monitor the evolution after treatment.

Lumbar posterior marginal node (LPMN) in adults. Report of fifteen cases

This report concerns 15 adults (nine men and six women) who experienced lumbar and sciatic pain associated with an unusual defect of the edges of the vertebral bodies together with a small bony ridge protruding into the spinal canal. This lesion was well demonstrated by computed tomography and easily differentiated from the posterior longitudinal ligament or herniated disc calcifications, as well as from posterior degenerative ridge osteophytes. This lesion looked like the so-called lumbar posterior marginal node. First described in adolescents, this entity was considered as a traumatic fracture of the posterior ring apophysis. Recently, identical cases were noted in young adults in the absence of previous trauma, which were a particular type of marginal cartilaginous node. In the cases reported here, the computed tomographic scans suggested several mechanisms of formation of the vertebral lesion: a variant of marginal cartilaginous nodes; traumatic avulsion; avulsion related to disc herniation; and fusion of the avulsed bony fragment with the vertebral body.

Rotation-abduction analysis in 10 normal and 20 pathologic shoulders. Elite system application

Kinematics of shoulder rotation-abduction in the plane of the scapula were analysed using the Elite system. We evaluated 10 asymptomatic subjects and 20 patients with painful conditions affecting the shoulder, 10 adhesive capsulitis and 10 rotator cuff-tears. The last pathologic cases were reexamined after rehabilitation treatment. The Elite system computed on line the trajectories of 8 retro reflective markers glued on the main reference points (3 on the spine, 3 on the scapula and 2 on the humerus). Angles and linear velocities were also evaluated. The lower humeral site displacement and gleno-humeral angle increase allowed differentiation of the normal shoulder rotation-abduction from the abnormal movement. Hence, rehabilitation progress could be followed up.

Stenosis of the lumbar spinal canal in vertebral ankylosing hyperostosis

Certain morphologic features frequently observed in radiography or computed tomography (CT) scan in patients with hyperostosis led us to study the association between a narrowed spinal canal and vertebral hyperostosis. Twenty-eight items were selected and studied by three different investigators (two rheumatologists and one radiologist) in radiographs and CT scans of 100 patients with acquired stenosis of the lumbar canal, with or without hyperostosis (46 and 54 cases, respectively). The most distinctive points that we suggest can be used as diagnostic criteria of the hyperostotic narrowed lumbar canal are anterior or posterior lateral marginal somatic osseous proliferations, proliferations of the nonarticular aspects of the posterior apophyses, and ossifications of the posterior articular capsule and of the ligaments (yellow ligament, posterior longitudinal ligament, and the supraspinal ligament). Four of these six criteria should be present to establish the diagnosis of hyperostotic lumbar stenosis. The appearance of lumbar hyperostosis on X-ray or CT scans differs from that of simple degenerative changes due to arthrosis, and the hyperostosis can be held responsible for dural compression.

[Effects of methotrexate on leukotriene and derivated lipoxygenase synthesis in polynuclear neutrophils in rheumatoid polyarthritis]

Methotrexate (MTX) has been proved to be effective in rheumatoid arthritis (RA). The mechanism of action of MTX in this disease remains unelucidated but may involve inhibition of the enzyme 5-lipoxygenase. Arachidonic acid metabolites were studied in eight patients with active RA immediately prior to and 24 hours after the first intramuscular injection of 10 mg MTX. None of the patients were taking corticosteroids. Nonsteroidal antiinflammatory drugs were withdrawn four days before the study. Reverse phase high-performance liquid chromatography was used to quantitate metabolites produced by 5-lipoxygenase (5-LO) and 12-LO in plasma (full spectrum of blood cells) and purified neutrophils (PN) after stimulation with calcium ionophore A 21387 (50 microM for 30 minutes and 5 microM for 5 minutes, respectively). LTB4 production by PNs was significantly decreased (-32%, p < 0.01) 24 hours after MTX administration. A moderate (-17%), nonsignificant (NS) fall in LTB4 omega-oxidation products (wP) was seen. Production of 5-HETE was also slightly decreased (-15%, NS). Findings in plasma were comparable, with a significant decrease in total LTB4 (-29.8%, p < 0.01) and moderate falls in wP (-18.8%, NS) and in 5-HETE production (-17%, NS). Production of 12-HETE was unchanged. These findings suggest that MTX in a single dose is responsible for a decrease in the synthesis of LTB4 and 5-LO products in neutrophils and other blood cells in RA patients but does not affect 12-LO activity.

Effects of a single dose of methotrexate on 5- and 12-lipoxygenase products in patients with rheumatoid arthritis

The inhibition of 5-lipoxygenase could be involved in the mechanism of action of methotrexate (MTX). We studied 8 patients with active rheumatoid arthritis (RA) immediately before and the day after the first dose of MTX (10 mg intramuscularly). Leukotriene B4 (LTB4) formation by polymorphonuclear leukocytes was significantly decreased (32%, p less than 0.01). This essentially involved released LTB4. A slight decrease was also obtained in omega-oxidation products. Similar results were obtained for plasma LTB4 (30%, p less than 0.02). A non-significant decrease in 5-HETE was noted. Conversely, 12-HETE was not modified. Our results suggest MTX has an effect on the 5-lipoxygenase pathway, particularly at the LTA4 epoxide hydrolase step, since 5-HETE and 6-trans-LTB4 isomers are not involved.