1/21. The power of the visible: the meaning of diagnostic tests in chronic back pain.This article explores the meaning of diagnostic tests for people with chronic back pain. Lower back pain is one of the most common health problems in the US. Five to ten percent of the patients who visit a primary care provider for back pain ultimately develop a chronic condition. We draw on interviews with chronic back pain patients in Atlanta, Dallas and Seattle to argue that testing constitutes an important element in the legitimation of pain for these patients. We discuss three aspects that make testing an area of concern for patients: a strong historical connection between visual images and the medicalization of the interior of the body, a set of cultural assumptions that make seeing into the body central to confirming and normalizing patients' symptoms, and the concreteness of diagnostic images themselves. Our interviews show that when physicians cannot locate the problem or express doubt about the possibility of a solution, patients feel that their pain is disconfirmed. Faced with the disjunction between the cultural model of the visible body and the private experience of pain, patients are alienated not only from individual physicians but from an important aspect of the symbolic world of medicine. This paper concludes by suggesting that a fluid, less localized understanding of pain could provide a greater sense of legitimacy for back pain patients.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/21. A case of spinal cord compression syndrome by a fibrotic mass presenting in a patient with an intrathecal pain management pump system.A 45-year-old woman presented with increasing low back pain, progressive anesthesia in her lower extremities and difficulty ambulating. She had a history of chronic low back pain problems for which, 26 months earlier, she had an intrathecal infusion pump permanently placed for pain and spasm control. Urgent magnetic resonance imaging (MRI) of the lumbar spine revealed a mass at the site of the tip of the intrathecal catheter with high grade spinal cord compression at the level of L-1. At surgical laminectomy the compressing lesion was found to be a reactive tissue fibroma. As more patients receive these devices the physician should consider cord compression syndrome in patients presenting with symptoms of increasing low back pain, anesthesia and progressive proprioceptive loss.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
3/21. syncope caused by nonsteroidal anti-inflammatory drugs and angiotensin-converting enzyme inhibitors.A 85-year-old woman with diabetes mellitus and prior myocardial infarction was transferred to the emergency room with loss of consciousness due to marked bradycardia caused by hyperkalemia. The T wave during right ventricular pacing was tall and tent-shaped while the concentration of serum potassium was high, and its amplitude during pacing was decreased after correction of the serum potassium level. Simultaneously with the correction, normal sinus rhythm was restored. The cause of hyperkalemia was considered to be several doses of loxoprofen, a nonsteroidal anti-inflammatory drug (NSAID), prescribed for her lumbago by an orthopedic specialist, in addition to the long-term intake of imidapril, an angiotensin-converting enzyme inhibitor (ACEI), prescribed for her hypertension by a cardiologist. This case warns physicians that the combination of NSAID and ACEI can produce serious side effects in aged patients who frequently suffer from hypertension, diabetes mellitus, ischemic heart disease, and degenerative joint disease.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
4/21. Fibro-fatty nodules and low back pain. The back mouse masquerade.BACKGROUND: Few useful interventions exist for patients with persistent low back pain. We suggest that a fibro-fatty nodule ("back mouse") may be an identifiable and treatable cause of this and other types of pain. methods: We describe 2 patients with painful nodules in the lower back and lateral iliac crest areas. In both cases, the signs and symptoms were unusual and presented at locations distant from the nodule. One patient complained of severe acute lower abdominal pain, and the other had been treated for chronic recurrent trochanteric bursitis for several years. RESULTS: In both patients, symptoms appeared to be relieved by multiple injection of the nodule. DISCUSSION: There is agreement that back mice exist. Referred pain from the nodules might explain the distant symptoms and signs in these cases. Multiple puncture may be an effective treatment because it lessens the tension of a fibro-fatty nodule. CONCLUSIONS: Randomized trials on this subject are needed. In the meantime, physicians should keep back mice in mind when presented with atypical and unaccountable symptoms in the lower abdomen, inguinal region, or legs.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
5/21. spondylolysis as a cause of low back pain in swimmers.low back pain (LBP) has recently become a common complaint in swimmers. The differential diagnosis of LBP in swimmers includes muscle and ligament sprains, Scheuerman disease, herniated disc, facet joint injury, tumors, infections, and spondylolysis. Although spondylolysis or listhesis is a frequent injury in the athlete, mainly in weightlifters, wrestlers, gymnasts, divers and ballet dancers, it is infrequently reported in swimmers. We have recently encountered four adolescent elite swimmers who complained of low back pain and were diagnosed as having spondylolysis. Three of the patients were either breast-strokers or butterfly swimmers. Plain radiography demonstrated the lesion in two patients. Increased uptake in bone scan was noted in all patients. CT was performed only in two patients and revealed the lesion in both. One patient was diagnosed within two weeks, and the diagnosis in the others was deferred for 2-7 months. The patients were treated successfully by reducing the intensity of their training program and the use of a corset for at least three months. Repeated hyperextension is one of the mechanisms for spondylolysis in athletes as is the case in breast-strokers and butterfly style swimmers. LBP in swimmers should raise the suspicion of spondylolysis. Plain radiography and bone scan should be performed followed by SPEC views, CT, or MRI as indicated. If the case is of acute onset as verified by bone scan, a boston or similar brace should be used for 3 to 6 months in conjunction with activity modification and optional physical therapy. Multidisciplinary awareness of low back pain in swimmers, which includes trainers, sport medicine physicians, and physical therapists, should lead to early diagnosis and appropriate treatment.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
6/21. Static magnetic field therapy for pain in the abdomen and genitals.Two adolescents with debilitating, medication-resistant, chronic pain of the low back and abdomen with intermittent pain of the genitalia were diagnosed with intervertebral disk disease at spinal cord levels that correlated with their signs. Both patients had undergone multiple evaluations by physicians of different specialties and both underwent appendectomy without relief of their pain. The history of the onset of pain was important in determining the affected levels. The pain of both individuals was mimicked and localized by percussion of the vertebral spines at the level of disk protrusion. This maneuver and careful review of the history were important in making the correct diagnosis in each case. In both patients, treatment with novel magnetic devices provided rapid relief that was sustained for more than 2 years. These cases highlight the need for careful evaluation and correct diagnosis of abdominal and genital pain in young patients to avoid costly and unnecessary medical intervention and the stigma of painful debility.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
7/21. Impairment and disability rating in low back pain.LBP is one of the two most common forms of disability in Western society (mental illness is the other), and remains a thorny problem in the arena of disability evaluation. disability evaluation after LBP differs whether the pain is work-related or not. If work-related, guidelines for disability evaluation differ by jurisdiction and type of employment (e.g., private vs. federal employee). When outside of the workplace, thresholds for disability differ between entitlement programs (social security Disability) and private insurance programs (long-term disability insurance). In the patient without obvious findings, the disability evaluating physician needs to be caring and compassionate and yet maintain an objective stance with the understanding that there may be significant psychosocial overlay in patients with nonobjective pain complaints. Although some would argue that objective independent medical evaluation is an oxymoron, psychiatrists have excellent training and perspective with which to do so. The patient suffering from catastrophic brain injury or spinal cord injury offers a useful contrast--on the most severe end of the disability spectrum--to the patient with persisting low back complaints but normal physical examination. As a society, we have to wisely manage the funds that comprise our social "safety net" in order to provide for persons with severe disability who cannot provide for themselves. It would then follow that patients with minor impairments/disabilities should receive minor (i.e., noninflated) ratings. Psychiatrists need to enable rather than disable their patients.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
8/21. Diagnosis of pain with a graduated spinal block technique.The differential spinal examination has been used at Duke University Medical Center for approximately 15 years in the evaluation of low-back and lower extremity pain. This is a technique of using increasing concentrations of procaine hydrochloride to block nerves of various sizes and degrees of myelinization. With the ever increasing number of compensation and liability cases, there is a corresponding need for this type of diagnostic and prognostic test. It is an attempt to give the physician an objective estimate of the pain. It must be stressed that this is just another test for diagnostic and prognostic evaluation. However, initial results seem to indicate that much weight can be placed on the findings in an attempt to objectively categorize the pain as being either organic or functional and whether it is medicated by sensory or sympathetic pathways.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
9/21. Atypical presentation of intramedullary spinal cord lesion.We report a patient who presented with atypical clinical manifestations including worsening abdominal pain from an intramedullary spinal cord lesion. It is important to consider non-abdominal causes of abdominal pain for patients with an atypical presentation. The described case demonstrates the challenges facing the physician with the early diagnosis of acute abdominal pain. Spinal cord lesions, although uncommon, remain a potentially disabling and life-threatening cause of abdominal pain.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
10/21. neck and low back pain.These cases represent a sample of conditions that impact the spine and paraspinous structures. Central to establishing a correct diagnosis and the cost-effective application of neurodiagnostic tests is a careful history and physical examination. The primary care physician is often the only physician to have a perception of the whole patient. The primary care physician is in an excellent position to initiate the evaluation of patients with spine symptoms and, where appropriate, monitor the treatment plans of consulting physicians.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
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