Cases reported "Back Pain"

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1/16. How to develop one's counseling--demonstration of the use of single-case studies as a practical tool for evaluating the outcomes of counseling.

    The physical activity patterns of eight single cases of back patients are described across a series of counseling sessions and a 12-month follow-up. The cases demonstrate the variability of physical activity during the counseling period due to random influences in the patient's life and the possibility of total relapse of more complicated activity types after counseling. The simple behaviors like proper sitting, standing or lifting are shown to be better maintained in spite of the random influences in the patient's life. The single-case study method is demonstrated to serve as a practical tool for evaluating one's counseling in the promotion of health-related physical activity.
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2/16. Disc herniation after lumbar fusion.

    STUDY DESIGN: Eight patients with a herniated disc after lumbar spinal fusion are reported. Their clinical features, imaging studies, and management are reported. OBJECTIVES: To identify the incidence and features of disc herniation above a spinal fusion, and to describe their management. SUMMARY OF BACKGROUND DATA: Late complications of lumbar spinal fusions have been reported in the literature, but disc herniation has not been specifically addressed in detail. The motion segment above a spinal fusion undergoes additional stresses, as documented by increased pressure and excessive motion, resulting in degenerative changes. These factors likely predispose to disc herniation. methods: Of 601 consecutive lumbar fusion cases over an 8-year period, herniated nucleus pulposus above the fusion was diagnosed in 8 patients. The clinical findings and imaging studies were reviewed, including a myelogram computed tomography scan, a magnetic resonance image with positive documentation of the herniation, or both. The management of these cases was reviewed. RESULTS: Eight patients (1.3%) (4 men and 4 women) were identified, whose average age was 56.4 years. Nonoperative treatment failed in six patients. Two of these patients underwent simple discectomy, and the remaining four underwent discectomy and fusion. All four patients went on to fusion. The average time from disc herniation onset to fusion was 28.4 months. CONCLUSIONS: Herniated disc after lumbar spinal fusion was found in approximately 1.3% of patients. Although rare, this entity that should be considered when patients complain of recurring back pain after a lumbar spinal fusion.
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3/16. Radicular compression by lumbar intraspinal epidural gas pseudocyst in association with lateral disc herniation. role of the posterior longitudinal ligament.

    Among unusual abnormalities of the lumbar spine reported since the introduction of Computed tomography (CT), the presence of gas lucency in the spinal canal, known as vacuum phenomenon, is often demonstrated. On the contrary, epidural gas pseudocyst compressing a nerve root in patients with a lateral disc herniation has rarely been reported. We report a case of a 44-year-old man who experienced violent low back pain and monolateral sciatica, exacerbated by orthostatic position, one week before admission. A lumbosacral spine CT showed the presence of vacuum phenomenon associated with a degenerated disc material and a capsulated epidural gas collection with evidence of root compression. A microsurgical interlaminar approach was carried out and, before the posterior longitudinal ligament was entered, a spherical "bubble" compressing the nerve roots was observed. The capsulated pseudocyst was dissected out, peeled off and excised en bloc. A large part of the posterior longitudinal ligament and the lateral disc herniation were removed. Postoperatively the patient was completely free of symptoms. The mechanism of exacerbation of pain was probably due to the increased radicular compression in the upright posture and, besides the presence of a lateral disc herniation, could be related to a pneumatic squeezing of gas from the intervertebral space into the well capsulated sac by the solicitated L4-L5 motion segment. Histological study of the wall of the pseudocyst showed the presence of fibrous tissue identical to the ligament. We conclude that, in case of a lumbar disc herniation, it is recommended to perform a complete microdiscectomy and an accurate removal of the involved portion of posterior longitudinal ligament in order to prevent pseudocystic formations.
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4/16. A new consideration in athletic injuries. The classical ballet dancer.

    The professional ballet dancer presents all of the problems of any vigorous athlete. The problems include osteochondral fractures, fatigue fractures, sprains, chronic ligamentous instability of the knee, meniscal tears, impingement syndrome, degenerative arthritis of multiple joints and low back pain. attention to minor problems with sound conservative therapy can avoid many major developments and lost hours. Observations included the extraordinary external rotation of at the hip without demonstrable alteration in the hip version angle and hypertrophy of the femur, tibia and particularly the second metatarsal (in female dancers). Careful evaluation of the range of motion of the extremities, serial roentgenographic examination, and systematic review of previous injuries, training programs and rehearsal techniques have been evaluated in a series of cases to provide the basis for advice to directors and teachers of the ballet.
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5/16. Early detection measures and triage procedures for suicide ideation in chronic pain patients.

    There is a dearth of writings about early detection of potential suicide patients in chronic pain centers. Early detection measures used at the Vanderbilt Pain Control Center include a Symptom checklist-90, with questions about depressive symptomatology and "Thoughts of Ending Your life"; medical and psychological interviews; monitoring of changes in emotional disturbance; and, if warranted, administration of the Scale of suicidal ideation. Three case studies are presented that indicate that the results of an assessment measure should be tempered with clinical judgment. Suicidal behavior, including suicidal ideation, is a medical emergency; therefore, there is great need for early detection and triage measures.
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6/16. The spine in fibrodysplasia ossificans progressiva: a case report.

    STUDY DESIGN: A case report of fibrodysplasia ossificans progressiva (FOP). OBJECTIVES: To report a very rare cause of back pain. SUMMARY OF BACKGROUND DATA: FOP is an autosomal dominant disorder with overexpression of bone morphogenetic protein 4 and negative HLA B27. Pathognomonic are congenital malformations of the big toes. methods: The authors report on a patient with FOP who presented with back pain at their outpatient clinic. RESULTS: On physical examination, several indurated masses were visible and palpable close to the left and right scapula and the thoracic spine. These were not tender or painful, nor warmed or inflamed. A significantly decreased range of motion of all levels of the spine and the shoulder were found. On the radiographs, segmentation defects of the cervical and lumbar spine as well as synostoses of the spinal processes were seen. The cervical vertebral bodies were small and unusually high. Heterotopic ossifications could be discerned in the lumbar postural muscles and the facet joints of the spine were ankylosed. Additionally to these findings, on the thoracic radiographs ossifications of the muscles of the shoulder girdle could be seen. The pathognomonic shortening of the first metatarsal bone and the proximal phalanx was bilaterally present. The surface shaded 3D-reconstruction of the computed tomography of the trunk showed multiple bulky and confluating ossifications of the shoulder girdle. The spinal processes of the thoracic spine were anklyosed by massive ossifications of the postural muscles. CONCLUSIONS: In FOP, diagnosis can be made by the typical clinical and radiological features.
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7/16. Pain flashbacks in posttraumatic stress disorder.

    OBJECTIVES: Surgical patients who regain consciousness while under general anesthesia may develop symptoms of Posttraumatic Stress Disorder (PTSD). One common PTSD symptom is the experiencing of abnormal perceptions during which the patient feels as if the trauma is recurring. The objective of this report is to document the re-occurrence of pain as part of the PTSD sequelae. RESULTS: We present two patients who developed PTSD following an episode of awareness under anesthesia. In both cases, posttraumatic sequelae persisted for years and included pain symptoms that resembled, in quality and location, pain experienced during surgery. In addition to their similarity to the original pain, these pain symptoms were triggered by stimuli associated with the traumatic situation, suggesting that they were flashbacks to the episode of awareness under anesthesia. DISCUSSION: The similarity between the patients' pain symptoms and pain experienced during trauma, the triggering by traumatic cues, and the associated emotional arousal and avoidance suggest the involvement of a somatosensory memory mechanism.
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8/16. Differential diagnosis and treatment in a patient with posterior upper thoracic pain.

    BACKGROUND AND PURPOSE: Determining the source of a patient's pain in the upper thoracic region can be difficult. Costovertebral (CV) and costotransverse (CT) joint hypomobility and active trigger points (TrPs) are possible sources of upper thoracic pain. This case report describes the clinical decision-making process for a patient with posterior upper thoracic pain. CASE DESCRIPTION: The patient had a 4-month history of pain; limited cervical, trunk, and shoulder active range of motion; limited and painful mobility of the right CV/CT joints of ribs 3 through 6; and periscapular TrPs. Interventions included CV/CT joint mobilizations, TrP release, and flexibility and postural exercises. OUTCOMES: The patient reported intermittent mild discomfort after 7 physical therapy sessions. Examination findings were normal, and he was able to resume all preinjury activities. DISCUSSION: This case suggests that CV/CT mobilizations and active TrP release may have been beneficial in reducing pain and restoring function in this patient.
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9/16. Iliopsoas myofascial dysfunction: a treatable cause of "failed" low back syndrome.

    Most patients with low back pain experience loss of spinal and hip extension range of motion. The limitation appears to involve significant iliopsoas myofascial dysfunction manifested in tenderness, as shown by deep abdominal palpation of the psoas muscle, hip flexor contracture, pain elicited by the stretch maneuver of the spine and hip, and relative weakness of the psoas muscle when tested manually. These signs assisted in identifying the source of low back pain in six patients who had failed to respond to prior treatment. Therapy consisted of iliopsoas trigger point treatment using a dry needling technique, followed by self-administered postisometric relaxation exercise of the iliopsoas. In all cases, marked improvement of hip and spine extension, dramatic reduction of pain, and return to normal activity resulted. Given the low risk-to-benefit ratio, trigger point treatment is indicated in "failed back syndrome" and chronic low back pain after conservative therapy or surgery have been tried without success.
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10/16. Diagnostic epidural opioid blockade and chronic pain: preliminary report.

    A technique is described which helps in the differentiation between pain of a mainly physical (organic) and emotional (psychogenic) basis. This is based upon the patients' subjective response to the epidural administration of fentanyl and placebo agents. patients initially had both physical and psychological assessment in a multidisciplinary pain management unit and because of doubt of the underlying diagnosis, were subjected to this procedure. Eight patients are described in whom the following solutions were administered at 20 min intervals: 2 aliquots of normal saline (5 ml) via an epidural catheter; 1 microgram/kg fentanyl via the epidural catheter; intravenous naloxone 0.4 mg, then, depending upon results obtained, 15-20 ml 2% plain lignocaine via the epidural catheter. If a patient's visual analogue score decreased following epidural fentanyl and subsequently increased following naloxone, then a predominantly physical basis for the pain was likely. In contrast, little change in visual analogue score following fentanyl and naloxone suggested a diagnosis of a predominantly emotional basis for the pain. The diagnoses were substantiated by subsequent follow-up and treatment. It is suggested that this test has both prognostic and diagnostic value when used in the context of thorough physical and psychologic assessment of a patient with chronic pain.
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