Immediate effect of sling exercises combined with mechanic vibration and oscillation mobilization in chronic nonspecific low back pain patients: a randomized controlled trial

PURPOSE

This study determined whether the combined application of sling exercises (SE) with targeted vibration and oscillations using a device called the Vibraoscillator (VO) is effective in reducing pain intensity, increasing range of motion (ROM), and enhancing back-related functions in patients with chronic nonspecific low back pain (CNLBP).

MATERIALS AND METHODS

Thirty-six participants were randomized into experimental (SE + VO) and control (SE) groups. Both groups received the intervention twice a week for 4 weeks. The pain was assessed using the Numerical Rating Scale (NRS), ROM was measured using the Modified-Modified Schober's Test (MMST), and the level of disability was evaluated using the Oswestry Disability Scale (ODI). In addition, the global perceived effect (GPE) was determined.

RESULTS

NRS and ODI scores significantly improved after the intervention in the experimental group. Only lumbar spine extension improved significantly in the case of ROM. The GPE satisfaction rate was 14.5% higher in the experimental group than in the control group.

CONCLUSION

Based on the findings obtained in this study, the combined use of VO and SE in patients with CNLBP was effective in reducing pain, improving ROM, and reducing physical disability in comparison with the treatment of only SE.IMPLICATIONS FOR REHABILITATIONChronic nonspecific low back pain is a major public health problem because it affects almost every person at least once in their lifetime.A new device called a Vibraoscillator generates horizontal vibrations and vertical oscillation movements targeted to a specific area of treatment to promote the neurofacilitation of the targeted zone, aiming for a more focused treatment than general vibrations.This device, in combination with sling exercises, is hypothesized to reduce pain and increase the mobility of the targeted zone and back-related functions in these patients.Based on our findings, the combined use of these interventions twice a week for 4 weeks was effective in reducing pain and improving the range of movement, which consequently reduced physical disability in patients with chronic nonspecific low back pain.

Trends Over Time in the Use, Carbon Footprint and Costs of Facet Joint Injections and Medial Branch Blocks to Manage Lumbar Pain in England: Retrospective Analysis of an Administrative Dataset

STUDY DESIGN

Retrospective analysis of an administrative dataset.

OBJECTIVE

This study aims to investigate changing practice over a six-year period in the use of repeated lumbar facet joint injections/medial branch blocks in England.

METHODS

Patient data were extracted from the Hospital Episodes Statistics database for the period 1st April 2015 to 31st March 2021 for the index lumbar injection and for repeat lumbar injections performed within one year of the first. The exposure of interest was two injections within 180 days or three within one year. Patients aged <17 years and where the body site was listed as cervical, thoracic or sacral were excluded.

RESULTS

Data were available for 134,249 patients of which, 8,922 (6.6%) had either two injections within 180 days or three injections within one year. First injections fell from 42,511 in 2015/16 to 13,368 in 2019/20 as did the number of repeat injections: 4,018 to 424 for the same period. If all years had the same carbon footprint as 2019/20, 2.8 kilotons of CO2e would have been saved over the five years, enough to power 2,575 average UK homes for 1 year. The financial cost of injections decreased from £27.6 million in 2015/16 to £7.9 million in 2019/20.

CONCLUSIONS

The number of patients having repeated lumbar injections has decreased over time but has not been eliminated. More work is needed to educate patients and clinicians regarding alternative and more effective treatments.

Lower Back Pain Imaging: A Readability Analysis

PURPOSE

The internet provides access to a myriad of educational health-related resources which are an invaluable source of information for patients. Lower back pain is a common complaint that is discussed extensively online. In this article, we aim to determine if the most commonly accessed articles about lower back pain imaging use language that can be understood by most patients. According to the American Medical Association (AMA) and National Institute of Health (NIH), this corresponds to a sixth-grade reading level.

METHODS

Online searches were conducted from the most commonly used search engine, Google, to assess the present state of readability on radiograph imaging for LBP. Then the top 20 populated URL links from each search were utilized based on "health & fitness" search trends and click-through rates (CTRs). The readability of various websites was evaluated with WebFX online software that analyzed the unique websites' text when put into reader view on Firefox web browser version 116.0.3 (64-bit). Evaluation occurred via five common readability indices: the Automated Readability Index (ARI), the Coleman Liau Index (CLI), the SMOG index, the Gunning Fog Score Index (GFSI), and the Flesch Kincaid Grade Level Index (FKGLI). In addition, the Flesch Kincaid Reading Ease Index (FKREI) was also used but was excluded from the calculation due to its measuring scale outside of US grade levels. The number of samples was analyzed via health and fitness-specific CTR from an open-access database from July 2022 to July 2023. This was used to calculate the number of persons clicking and visiting positional URLs (first URL to the 20th URL) from each unique keyword search and the rational criteria for selecting the first 20 websites for each query.

RESULTS

Online material that included LBP imaging information was calculated to have an overall readability score of 10.745 out of the 23 websites obtained from unique searches. The range was a mean readability score of 8 to 14. Notably, 17 websites were excluded from a total of 40 websites due to duplication of the same data (URLs that resulted from both unique searches) and accessibility requiring payment (specifically, an UpToDate link). A readability score of 10.745 refers to an 11th-grade reading level. That is to say, the most commonly visited sites on Google that contain information about lower back pain imaging are, on average, five grade levels higher than the sixth-grade reading level recommended by the AMA and the NIH.

CONCLUSIONS

Most internet content regarding lower back pain imaging is written at a reading level that is above the recommended limit defined by the AMA and NIH. To improve education about lower back pain imaging and the patient-physician relationship, we recommend guiding patients to online material that contains a reading level at the sixth-grade level as suggested by the AMA and NIH.

The Necessity of Extensive Decompression for Spinal Epidural Hematoma: A Case Report and Literature Review

Spinal epidural hematomas (SEHs)are space-occupying lesions that exert pressure on the spinal cord by rapidly accumulating blood between the dura and bone or ligament components. The annual incidence of spontaneous epidural hematoma is estimated to be one in one million. The predominant symptoms are back pain or neurological impairment, including sensory, motor, or autonomic dysfunction of the limbs below the hematoma level. Depending on the level and size of the hematoma and the affected cord, they cause neurological deficits. Neurological deficits are often reversible if diagnosed and treated early with surgical decompression. However, neurological deficits can become permanent if the patient is not operated on timely, and paraplegia or quadriplegia may occur. A 53-year-old man presented to our emergency department with acute-onset back pain and 36-hour-long, rapidly progressive paraparesis of both legs. On T1- and T2-weighted MRI scans, a hyperacute SEH was found as iso/hyperintense and hyperintense, respectively. Immediate decompressive laminectomy from T10 to L2 and hematoma evacuation were performed. It was challenging to remove the hematoma due to its firm consistency. Before performing a bilateral total laminectomy at five levels, the posterior spine was stabilized between T10 and L3 using transpedicular screws. Within 24 hours, the motor function of the lower limbs increased considerably. The patient could sit on a chair because of posterior stability. In addition to the importance of early diagnosis using imaging techniques, planning the extension of SEH surgery is crucial for the patient's postoperative neurological recovery.

A pacemaker lead infection as a complication of a discitis post fall in an elderly: A case report

The population around the world is growing in age, and taking care of the elderly has become a medical challenge as new pathologies, risk factors, treatments, and approaches are being explored. One of the most important chapters that should be focused on is falls in the elderly, as it is a common reason for, not only fractures but also dependency, morbidity, and mortality in this population. The chapter on fall is vast and can be further categorized. In this article, we aim to focus on one of the complications, which is discitis post-vertebral fracture. The patient studied was a 78-year-old female patient who consulted post-fall and was admitted to the geriatric ward for a vertebral fracture. The hospitalization was complicated by a spinal infection and later on by a rarely-seen pacemaker lead infection. Vertebral fractures are very common in the geriatric population, whether spontaneously or post-trauma. Although treatment can be surgical or conservative, complications are commonly seen and can be fatal. Discitis is a medical challenge as the germs can be difficult to isolate, the pain management is difficult and in frail elderly patients, the infection and inflammation can be fatal. Prevention of falls is important in the elderly population as a simple slip can have drastic outcomes. Understanding the possible complications of falls is essential for better management.

Sacral Chordoma Presenting as Back Pain in the Chiropractic Clinic: A Case Report

Cases of lumbar and gluteal pain are commonly encountered in chiropractic clinics, with a broad differential diagnosis primarily centered on musculoskeletal conditions. This report presents the second documented case of sacral chordoma diagnosed at a chiropractic clinic and emphasizes the importance of considering alternative diagnoses and interdisciplinary collaboration in patient care. A 42-year-old man presented to a chiropractic clinic with complaints of lumbar and gluteal pain. The initial conservative management based on a presumptive musculoskeletal diagnosis was ineffective. Suspicion of an alternative etiology prompted a referral for imaging, which revealed a sacral chordoma. An interdisciplinary collaboration involving orthopedic surgeons, oncologists, radiologists, and other healthcare professionals was initiated to optimize the treatment outcomes of this rare and aggressive tumor. This case report underscores the importance of maintaining a high index of suspicion in cases of musculoskeletal presentations in chiropractic clinics and the critical role of advanced imaging in establishing a definitive diagnosis. Interdisciplinary collaboration is essential for managing complex conditions such as sacral chordomas, ensuring the delivery of the highest quality of care, and optimizing patient outcomes. Chiropractors play a crucial role in identifying, referring, and contributing to the management of patients with complex presentations as part of a comprehensive multidisciplinary treatment plan.

Use of a non-medicated plaster in chronic lumbar back pain: a randomized controlled trial

BACKGROUND

The latest technology on far infrared radiations reflects the radiations emitted by the human body and induces an antalgic and anti-inflammatory effect without active ingredients. Our primary aim was to assess pain level modifications throughout the treatment period with two different types of patches, compared to a placebo. As secondary aims, we focused on addressing patients' quality of life and range of motion changes with each patch.

METHODS

We assessed 54 patients with chronic lumbar back pain treated with FIT Therapy (far infrared technology) patch. Three different types of FIT Therapy patches (F4, F3, and placebo) were used according to the different power of action and patients allocated in a randomized fashion into the 3 arms of the study. Every single patient was assessed during the study using the VAS pain scale, the Roland Morris Disability Questionnaire for quality of life, and ROM for a total of 14 days.

RESULTS

Only the F4 patch group significantly reduced pain level at T14 compared to the placebo group (p<0.05). Meanwhile, F3 showed only a non-significant decrease compared to placebo (p=0.254). In terms of lifestyle improvements, both F3 and F4 recorded a decrease on the RMDQ of 4 and 6 points, respectively.

CONCLUSIONS

Currently, we still need further studies with longer follow-up to consider the FIT Therapy patches F4 a valid alternative as a "non-medicated pain relief", but it proved to have a role in alleviating painful symptoms and improving function in chronic lumbar back pain without adverse events.

Early diagnosis and management of maternal ureterohydronephrosis during pregnancy

Maternal ureterohydronephrosis (UHN) is a common anatomical change during the evolution of pregnancy, diagnosed especially after the 20th week of pregnancy. The aim of the present study was to evaluate the stages of UHN during pregnancy, depending on the gestational age, and to monitor the symptomatology and the adequate management. A total of 58 pregnant women with UHN, hospitalized in the Constanta County Emergency Hospital, were included in the present study, and had nephrological monitoring using ultrasound examination. Right UHN was observed in all cases and left UHN was observed in only 67.24% of the cases. Regarding the gestational age, right UHN grade III was most commonly seen between 27 and 31 weeks of pregnancy (48.6% of total right UHN grade III from the studied group). The data showed that gestational age and grade of UHN had a highly dependent association in the studied group. The majority of our patients (67.24%) were symptomatic, and the most common complaint on presentation was lumbar pain. According to the visual analog scale (VAS) of the lumbar pain, the group could be distributed as follows: 17.24% with severe pain, 36.21% with moderate pain and 13.79% with mild pain. Eight pregnant women (13.79%) from the present study developed UHN due to passage of a ureteral stone, although the majority of the patients experienced complications with urinary tract infection and acute kidney injury. In addition, 97% of the symptomatic UHN responded to conservatory treatment and only 2 patients (3.45%) with severe symptomatic UHN needed ureteral stent insertion. Data analysis was performed using IBM SPSS Statistics 23. The study highlighted the existence of an association between gestational age and UHN grading.

Association between pain and gait instability in patients with lumbar disc herniation

Objective

To determine whether pain is associated with gait instability in patients with lumbar disc herniation (LDH).

Methods

This retrospective cross-sectional study used data from electronic medical records. Among patients with lumbar back pain caused by LDH between January 2017 and July 2019, patients that underwent gait analysis were included. LDH was diagnosed using magnetic resonance imaging. An OptoGait photoelectric cell system was used for gait evaluation. Instability was measured using a gait symmetry index. Multivariate linear regression analysis was performed to determine the association between lumbar pain and gait instability.

Results

A total of 29 patients (12 females [41.4%] and 17 males [58.6%]; mean ± SD age, 40.6 ± 12.0 years) with LDH were enrolled in the study. With each 1-point increase in lumbar pain on the numeric rating scale, the symmetry index of the stance phase (0.33; 95% confidence interval [CI] 0.04, 0.62), swing phase (0.78; 95% CI 0.14, 1.43) and single support (0.79; 95% CI 0.15, 1.43) increased.

Conclusions

Gait instability in patients with LDH may occur due to an increase in pain.

Inferior Vena Cava Syndrome: A Rare Complication

Inferior vena cava syndrome is rare and often difficult to diagnose because of its rarity and consequent low suspicion.

We describe the case of a 28-year-old female patient with a history of nephroblastoma of the right kidney, stage IV, with a favourable histology with epidural metastasis (D5–D9), diagnosed at 3 years of age. The patient underwent treatment with surgery, chemotherapy and radiotherapy.

The patient suffered from sudden low back pain worsening over 2 weeks, with progressive inability to walk. The pain radiated to the front of the thighs. Concomitantly, oedema of the lower limbs with cephalocaudal progression was observed. At admission to our institution, the physical examination showed peripheral oedema, abdominal wall venous collaterals, an inability to walk due to low back pain in the supine position, with no neurological deficits. Lumbar MRI showed exuberant epidural venous congestion. The hypothesis of inferior vena cava thrombosis (IVCT) was considered and confirmed by angio-CT.

IVCT is prevalent in patients with congenital anomalies of the inferior vena cava, occurring in approximately 60–80% of these cases, and most published series on inferior vena cava syndrome refer to thrombotic complications in this subgroup of patients. There are currently no guidelines defined or validated to guide the diagnosis and approach to IVCT. With this case, we would like to draw attention to a rare disease that should be suspected in all patients with inferior vena cava disease, whether resulting from congenital disease or after surgical procedures.

Different types of low back pain in relation to pre- and post-natal maternal depressive symptoms

Background

Low back pain (LBP) is a common musculoskeletal problem during pregnancy, with an estimated prevalence ranging from 30–78% (Mota MJ et al. J Back Musculoskelet Rehabil 28(2):351-7,2015 and Abebe E et al. J Med Sc Tech 3(3). 37-44,2014). Women reporting LBP are at increased risk of developing perinatal depression. Pregnancy-related LBP is highly heterogeneous and can be divided into lumbar pain (LP), posterior pelvic pain (PPP), and combined pain (CP). Therefore, the purpose of this study was to investigate the associations between LBP and perinatal depressive symptoms.

Methods

This was a retrospective case-control study conducted from January 2016 to April 2019. A total of 484 pregnant women were enrolled in this study: a case group of 242 pregnant women who were diagnosed with LBP and an age-matched control group of 242 pregnant women without LBP. The Edinburgh Postnatal Depression Scale (EPDS), LBP characteristics, and questionnaires about pregnancy that included demographic, parity, work, comorbidity, and previous pregnancy data were completed and compared between the case group and the control group.

Results

A total of 68 of 242 (28.1%) women experienced PPP, 142 (58.7%) had lumbar pain(LP), and 32 (13.2%) had combined pain. Furthermore, 26.5% of women with prenatal depression in the LP subgroup remained depressed 6 months postnatally, while the percentages for women in the PPP subgroup and CP subgroup were just 10.6% and 15.6%, respectively. The percentage of women who recovered anytime between delivery and six months postnatally in the PPP subgroup was significantly higher than that in the LP subgroup (31.7% vs. 14.7%, P < 0.001).

Conclusions

There is a difference in the prevalence of prenatal, postnatal, and perinatal depressive symptoms among pregnant women with different types of LBP. It is necessary to screen prenatal and postnatal depression separately and differentiate the types of LBP during pregnancy. Attention to these factors may help to outline better management strategies to improve maternal health.

[The conservative treat ment of patients with degenerative lumbar stenosis]

AIM

To study factors affecting the course of lumbar stenosis (LS).

MATERIAL AND METHODS

In the course of a two-year prospective study, 68 patients with degenerative LS, aged from 51 to 88 years (mean age 66±15.4 years), 21 men and 47 women, were examined. The 1st group consisted of 30 patients with stenosis of the lateral pocket (lateral LS), the 2nd group included 39 patients with central LS.

RESULTS AND CONCLUSION

For patients of the 1st group, significant risk factors for disease progression were spondylolisthesis, pain intensity in the lumbar region during walking, pain intensity in the leg during walking, the degree of LS, while the most significant parameter was spondylolisthesis (regression coefficient was 17.59; p=0.006). A risk factor for the lack of recovery/deterioration in the patients of the 2^nd group was expressed LS, which twice worsened the prognosis of the disease (regression coefficient - 14.79; p=0.003983). The presence of spondylolisthesis in patients with central LS was a risk factor for lack of recovery, but not deterioration. The absence of therapeutic exercise was a risk factor for the progression of the disease.

Retained Curved Needle After Balloon Kyphoplasty: A Complication with a Novel Device and Its Management

To date, no case studies specifically describing a curved kyphoplasty needle becoming lodged in the vertebral body with the inability to be withdrawn have been reported. We describe a case involving a single level balloon kyphoplasty with a curved coaxial needle during which the cement delivery device could not be removed after cavity filling. In this case, a board-certified interventional pain management specialist was performing balloon kyphoplasty for an L2 osteoporotic vertebral compression fracture. The tools utilized in this procedure included flexible curved instruments designed to traverse the vertebral body and achieve uniform cement distribution through a unipedicular approach. Cannulation and cavity formation were completed without issue. Upon conclusion of cement filling, the curved cement delivery device was unable to be removed. After several attempts to remove the needle and consultation with both the device company and local spine surgeons, it was agreed that the device should be cut at the level of entry into the pedicle and left as a retained foreign object. The involved area was surgically exposed, the retained instrument was cut flush to the pedicle, and the free portion was removed without further complication. The patient followed up in clinic several months later without evidence of neurologic complications. Considerations when using a curved kyphoplasty device and a method of resolution when faced with the inability to remove such an instrument are discussed.

Low Back Pain: A Pain That May Not Be Harmless

Abdominal aortic aneurysms are defined as vascular dilatations greater than 50% of the normal proximal segment or those that have a maximum diameter above 3 cm. Risk factors include male gender, age over 75 years, history of vascular pathology, hypertension and arteriosclerosis. The Authors describe a case of a 74-year-old man, evaluated in an emergency setting for right lumbar pain lasting 4 days. The pain did not respond to analgesia and became progressively worse. Due to the severity of symptoms, CT angiography was performed, which showed an active rupture of a partially contained aneurysm associated with aortic dissection. Early diagnosis and timely management of aortic aneurysms are essential in preventing complications, namely rupture (50–83% patients die after rupture and before receiving medical care). Acute aortic dissection is a surgical emergency and the risk of rupture is proportional to the size of the aneurysm and its rate of growth.

Resolution of a Greater Than 50-year History of Severe, Chronic Low Back Pain Following an Ultrasound-guided Platelet-rich Plasma Infiltration of the Thoracolumbar Fascia

The diagnosis of chronic low back pain is a scourge of society that does not take into account the pathoanatomical cause of pain. This case describes a six-year search for the pinpoint pathoanatomical diagnosis of a patient's 50-plus year history of debilitating chronic low back pain after he failed the standard nonoperative and operative treatment modalities. Ultrasound-guided diagnostic blocks identified a potential space within the thoracolumbar fascia. This was treated with platelet-rich plasma, yielding a complete resolution of his pain and a full return to normal activities of daily living for three years since the procedure.

Implementing Yoga Into the Management of Patients With Refractory Low Back Pain in an Outpatient Clinic Setting

Purpose: To evaluate the effectiveness of implementing yoga into the treatment of patients with chronic low back pain. Design: Quantitative analysis with opportunity for qualitative feedback. Method: Effectiveness of this complementary treatment was assessed using a pretest/posttest design of patients who volunteered to participate in yoga classes as part of their back pain management. Measurements included low back pain rating, perception of back pain interference with daily activities, and self-efficacy in dealing with chronic low back pain. Findings: Although no statistically significant findings were found due to the small sample size, most participants demonstrated improved individual scores on all measurement surveys including qualitative comments. Conclusion: Based on the findings of this pilot study, further studies on implementing yoga into the treatment of chronic low back pain are encouraged.

[Surgical treatment of pain syndrome in lumbar spine in patients with obesity]

AIM

To analyze the reduction of pain severity, time of surgery, intraoperative blood loss, incidence of unintentional lesion of dura mater, infectious complications and hospital-stay after lumbar microdiscectomy.

MATERIAL AND METHODS

The study included 104 patients aged 24-58 years (37 men and 67 women, mean age 45 years) who underwent lumbar microdiscectomy within January 2015 - June 2016. The main and control groups consisted of 48 and 56 patients with and without obesity respectively. In all cases lumbar microdiscectomy was made. Pain syndrome was assessed by visual analogue scale and Oswestry questionnaire.

RESULTS

In 6 weeks, 6 and 12 months after surgery significant improvement of both lumbar and leg pain was observed. Significantly reduced pain was stable and similar in both groups within follow-up although there was a tendency to increased pain in long-term period in group 1. Blood loss and infections were slightly higher in obese group while surgery time and hospital-stay were significantly higher in these patients.

CONCLUSION

Features of patients with excessive body weight should be considered prior to elective surgery. Probably, implants are advisable to stabilize spinal motion segment and improve the outcomes among patients with excessive body weight.

Spondylectomy for Giant Cell Tumor After Denosumab Therapy

STUDY DESIGN

A case report.

OBJECTIVE

To report a case of the lumbar giant cell tumor (GCT) utilizing a new clinical treatment modality (denosumab therapy), which showed a massive tumor reduction combined with the L4 spondylectomy.

SUMMARY OF BACKGROUND DATA

There are some controversies about spinal GCT treatments. Denosumab has provided good clinical results in terms of tumor shrinkage, and local control in a short-time follow-up clinical study phase 2, although for spinal lesions, it has not been described. Nonetheless, "en bloc" spondylectomy has been accepted as being the best treatments modalities in terms of oncological control.

METHODS

A case study with follow-up examination and series radiological assessments 6 months after therapy started, followed by a complex spine surgery.

RESULTS

The denosumab therapy showed on the lumbar computed tomography scans follow-up 6 months later, a marked tumor regression around 90% associated to vertebral body calcification, facilitating a successful L4 spondylectomy with an anterior and posterior reconstruction. The patient recovered without neurological deficits.

CONCLUSION

A new therapeutic modality for spinal GCT is available and showing striking clinical results; however, it is necessary for well-designed studies to answer the real role of denosumab therapy avoiding or facilitating complex spine surgeries as spondylectomies for spinal GCT.

LEVEL OF EVIDENCE

5.

Influence of depression symptoms on patient expectations and clinical outcomes in the surgical management of spinal stenosis

OBJECT

This prospective cohort study was designed to determine the influence of depressive symptoms on patient expectations and the clinical outcomes of the surgical management of lumbar spinal stenosis.

METHODS

Patients with an age > 45 years, a diagnosis of lumbar spinal stenosis at one level, and an indication for decompressive surgery were included in this study. Data for all of the following parameters were recorded: age, sex, highest level of education, and employment status. Depression symptoms (Beck Depression Inventory), disability (Oswestry Disability Index), and back and leg pain (visual analog scale) were assessed before surgery and at 12 months thereafter. The reasons for surgery and patient expectations (North American Spine Society lumbar spine questionnaire) were noted before surgery. The global effectiveness of surgery (Likert scale) was assessed at the 1-year follow-up.

RESULTS

Fifty-eight patients were divided into two groups based on the presence (Group 1) or absence (Group 2) of depressive symptoms preoperatively; each group comprised 29 patients. Demographic data were similar in both groups before surgery. The main reason to undergo surgery was "fear of a worse situation" in 34% of the patients in Group 1 and "to reduce pain" in 24% of the patients in Group 2. The most prevalent expectation was to improve my social life and my mental health in both groups. Surgery had a relieving effect on the depressive symptoms in 14 patients (48%). Thus, in the postoperative period, the number of patients who were free of depressive symptoms was 43 compared with the 15 who were depressed (p = 0.001). The 15 patients with persistent depression symptoms after surgery had a worse clinical outcome compared with the 43 patients free of depression symptoms at the 1-year follow-up in terms of severe back pain (20% vs. 0%, respectively), severe leg pain (40% vs. 2.3%, respectively), and severe disability (53% vs. 9.3%, respectively). Only 33% of patients with persistent depression symptoms after surgery chose the option "surgery helped a lot" compared with 76% of patients without depression symptoms. Moreover, in terms of expectations regarding improvement in back pain, leg pain, walking capacity, independence, physical duties, and social activities, fewer patients were "completely satisfied" in the group with persistent depression symptoms after surgery.

CONCLUSIONS

Surgery for spinal stenosis had a relieving effect on preoperative depression symptoms at the 1-year follow-up. The persistence of depressive symptoms after surgery correlated with a worse clinical outcome and a higher rate of unmet expectations. Screening measures to detect and treat depression symptoms in the perioperative period could lead to better clinical results and increased patient satisfaction.

Over-, under- and misuse of pain treatment in Germany

BACKGROUND

The HTA-report (Health Technology Assessment) deals with over- and undertreatment of pain therapy. Especially in Germany chronic pain is a common reason for the loss of working hours and early retirement. In addition to a reduction in quality of life for the affected persons, chronic pain is therefore also an enormous economic burden for society.

OBJECTIVES

Which diseases are in particular relevant regarding pain therapy?What is the social-medical care situation regarding pain facilities in Germany?What is the social-medical care situation in pain therapy when comparing on international level?Which effects, costs or cost-effects can be seen on the micro-, meso- and macro level with regard to pain therapy?Among which social-medical services in pain therapy is there is an over- or undertreatment with regard to the micro-, meso- and macro level?Which medical and organisational aspects that have an effect on the costs and/or cost-effectiveness have to be particularly taken into account with regard to pain treatment/chronic pain?What is the influence of the individual patient's needs (micro level) in different situations of pain (e. g. palliative situation) on the meso- and macro level?Which social-medical and ethical aspects for an adequate treatment of chronic pain on each level have to be specially taken into account?Is the consideration of these aspects appropriate to avoid over- or undertreatment?Are juridical questions included in every day care of chronic pain patients, mainly in palliative care?On which level can appropriate interventions prevent over- or undertreatment?

METHODS

A systematic literature research is done in 35 databases. In the HTA, reviews, epidemiological and clinical studies and economic evaluations are included which report about pain therapy and in particular palliative care in the years 2005 till 2010.

RESULTS

47 studies meet the inclusion criteria. An undertreatment of acupuncture, over- and misuse with regard to opiate prescription and an overuse regarding unspecific chest pain and chronic low back pain (LBP) can be observed. The results show the benefit and the cost-effectiveness of interdisciplinary as well as multi-professional approaches, multimodal pain therapy and cross-sectoral integrated medical care. Only rough values can be determined about the care situation regarding the supply of pain therapeutic and palliative medical facilities as the data are completely insufficient.

DISCUSSION

Due to the broad research question the HTA-report contains inevitably different outcomes and study designs which partially differ qualitatively very strong from each other. In the field of palliative care hospices for in-patients and palliative wards as well as hospices for out-patients are becoming more and more important. Palliative care is a basic right of all terminally ill persons.

CONCLUSION

Despite the relatively high number of studies in Germany the HTA-report shows a massive lack in health care research. Based on the studies a further expansion of out-patient pain and palliative care is recommended. Further training for all involved professional groups must be improved. An independent empirical analysis is necessary to determine over or undertreatment in pain care.

What is adolescent low back pain? Current definitions used to define the adolescent with low back pain

Adolescent low back pain (ALBP) is a common form of adolescent morbidity which remains poorly understood. When attempting a meta-analysis of observational studies into ALBP, in an effort to better understand associated risk factors, it is important that the studies involved are homogenic, particularly in terms of the dependent and independent variables. Our preliminary reading highlighted the potential for lack of homogeneity in descriptors used for ALBP. This review identified 39 studies of ALBP prevalence which fulfilled the inclusion criteria, ie, English language, involving adolescents (aged 10 to 19 years), pain localized to lumbar region, and not involving specific subgroups such as athletes and dancers. Descriptions for ALBP used in the literature were categorized into three categories: general ALBP, chronic/recurrent ALBP, and severe/disabling ALBP. Whilst the comparison of period prevalence rates for each category suggest that the three represent different forms of ALBP, it remains unclear whether they represented different stages on a continuum, or represent separate entities. The optimal period prevalence for ALBP recollection depends on the category of ALBP. For general ALBP the optimal period prevalence appears to be up to 12 months, with average lifetime prevalence rates similar to 1-year prevalence rates, suggesting an influence of memory decay on pain recall.

A vascular cause of painful lumbar transverse syndrome

BACKGROUND

Despite typical signs of Leriche syndrome, this patient was misdiagnosed with disk prolapse. Vascular insufficiency, such as aortic occlusion, may underlie a motor-sensory deficit in the lower extremities.

METHOD

Case report.

FINDINGS

A 67-year-old woman was admitted for cramping pain in the lumbar spine, hips, and legs; diffuse weakness and sensory disturbances of both legs for weeks; and a cold feeling and livid colorization of the legs. Her complaints were attributed to a disk prolapse L5/S1, for which she underwent immediate laminectomy. Postoperatively, symptoms and signs were aggravated, abdominal pain developed, and C-reactive protein and creatinine were elevated. On the fourth postoperative day, femoral pulses were no longer palpable, anuria developed, and computed tomographry angiography showed occlusion of the abdominal aorta distal to the superior mesenteric artery and absent kidney perfusion. The patient died one day later. Postmortem review showed a visible intra-aortic mass on the previous lumbar magnetic resonance image.

CONCLUSIONS

The differential diagnosis of painful lumbar transverse syndrome should include vascular disease. Misinterpretation of a Leriche syndrome as a disk prolapse has not been reported.