461/573. A risk/benefit analysis of spinal manipulation therapy for relief of lumbar or cervical pain. Approximately 12 million Americans undergo spinal manipulation therapy (SMT) every year. Renewed interest in this method requires an analysis of its reported risks and possible benefits. This review describes two patients with spinal cord injuries associated with SMT and establishes the risk/benefit ratios for patients with lumbar or cervical pain. The first case is a man who underwent SMT for recurrent sciatica 4 years after chemonucleolysis. During therapy, he developed bilateral sciatica with urinary hesitancy. After self-referral, myelography demonstrated a total block; he underwent urgent discectomy with an excellent result 3 months after surgery. The second patient with an indwelling Broviac catheter and a history of lumbar osteomyelitis underwent SMT for neck pain. Therapy continued for 3 weeks despite the development of severe quadriparesis. After self-referral, he underwent an urgent anterior cervical decompression and removal of necrotic bone and an epidural abscess with partial neurological recovery. An analysis of these cases and 138 cases reported in the literature demonstrates six risk factors associated with complications of SMT. These include misdiagnosis, failure to recognize the onset or progression of neurological signs or symptoms, improper technique, SMT performed in the presence of a coagulation disorder or herniated nucleus pulposus, and manipulation of the cervical spine. Clinical trials of SMT have been summarized in several recent articles.(ABSTRACT TRUNCATED AT 250 WORDS) ( info) |
462/573. Paraspinal mapping: quantified needle electromyography in lumbar radiculopathy. In the diagnosis of low back pain, the presence of a high percentage of false positive findings on radiologic imaging studies has lead to a more definitive role for electrodiagnosis as a confirmatory test. The paraspinal muscles are a crucial part of the electrodiagnostic examination for radiculopathy. To date, no technique for paraspinal evaluation has been validated. Based on previously documented anatomical techniques, we have designed a method of paraspinal examination termed "paraspinal mapping" (PM). Electromyographic (EMG) needles are placed in five carefully chosen locations and inserted in multiple directions. Individual scores for these insertions are added to determine a total PM sensitivity score. The first 50 studies using PM were compared to peripheral EMG, imaging studies, and pain drawings. Results indicate that the technique is easy to perform. Sensitivity scores relate well with these tests. In this limited and uncontrolled population, PM had higher sensitivity for abnormalities than either peripheral EMG or imaging studies. Because of the anatomical validity of PM, future studies may show it to be useful in localizing the level of radiculopathy independently from peripheral EMG, and to support clinical findings and imaging studies. ( info) |
463/573. Electrodiagnostic testing in back and extremity pain. OBJECTIVE: The usefulness of electrodiagnostic testing by the primary care provider is shown in two cases of suspected compression-type neural lesions of the lumbar spine. CLINICAL FEATURES: A 54-yr-old female with acute lumbar spine pain that radiated into the hip and a 26-yr-old male with sharp gluteal pain that radiated into the thigh and ankle were admitted into an inpatient care facility for intensive therapy. Plain film radiographs were obtained initially. In addition, electrodiagnostic testing was performed to evaluate the L5 and S1 nerve roots, which suggested compressive-type lesions. Non-enhanced CT of the lumbar spine was performed and revealed central disk herniation or protrusion in each case. INTERVENTION AND OUTCOME: One patient exhibiting central compression signs of bladder dysfunction was referred for medical intervention. The remaining patient received flexion-distraction type of chiropractic manipulation with physiologic therapeutics and was discharged to outpatient care after 16 days. CONCLUSIONS: Electrodiagnostic testing can provide the primary care provider the data needed to make an informed decision regarding advanced imaging studies and to institute appropriate therapy or to intelligently refer a patient for follow-up. ( info) |
464/573. Nonoperative management of lumbar spinal stenosis. OBJECTIVE: To describe the successful treatment of a patient with lumbar spinal stenosis utilizing nonoperative procedures. CLINICAL FEATURES: A 76-yr-old male with a chief complaint of low back pain and left lower extremity pain demonstrated the following per history and physical examination: 1. A right antalgic shift. 2. Restricted lumbar range of motion with provocation of left lower extremity pain during extension. 3. Generalized lumbar spondylosis as revealed on plain film X rays. 4. MRI confirmed lumbar stenosis. A diagnosis of lumbar spinal stenosis secondary to spondylosis was made. INTERVENTION AND OUTCOME: Twelve treatments of flexion-distraction manipulation, deep tissue massage, ultrasound, therapeutic exercise, heel lift, and modification of activities of daily living. He was discharged from care asymptomatic in 3 wk. Objective improvement was also noted. CONCLUSIONS: Conservative treatment designed to increase lumbar flexion, thus increasing lumbar spinal canal volume, has a positive influence on the diminution of neural ischemia and its resultant neural dysfunction. Additional research is needed to elucidate these concepts. ( info) |
465/573. A case of acute encephalopathy after iohexol lumbar myelography. A case of acute encephalopathy after lumbar myelography is reported in a female aged 26 years. Fourteen hours after the procedure, the patient developed coma (GCS 6) and had generalized slowing of EEG activity. This state lasted about 12 h, followed by gradual and full recovery. ( info) |
466/573. body composition, endurance, strength, cross-sectional area, and density of MM erector spinae in men with and without low back pain. Thirty-six 45-55-year-old men with healthy low backs were studied with respect to body composition, isokinetic and isometric trunk strength, trunk muscle endurance, and cross-sectional area and radiological density of mm erector spinae. Results were compared to those of men in the same age group with intermittent low back pain (LBP) (n = 91) and with chronic LBP (n = 21). The back healthy group was significantly stronger and had longer trunk muscle endurance times than men with chronic LBP. men with intermittent LBP had strength and endurance values in between the back healthy and chronic groups. There were no significant differences between any of the groups with respect to body composition and cross-sectional area of mm erector spinae. Radiological density for mm erector spinae was significantly decreased in the chronic LBP group compared to the back healthy and intermittent LBP groups. The deconditioning syndrome and its relationship to intermittent and chronic LBP is discussed. ( info) |
467/573. In search of the 'back mouse'. The "back mouse" is a tender, fibrous, fatty subcutaneous nodule found in the lumbosacral area in up to 16% of people. It can be a treatable cause of low back pain that may be unrecognized by both specialists and generalists. ( info) |
468/573. Intraosseous lipomas. Intraosseous lipomas are considered to be rare tumours. We describe four cases and discuss their appearances and diagnosis. It is likely with the increasing frequency of computed tomography and magnetic resonance examinations of the lumbar spine that many more asymptomatic lesions will present to the radiologist and that these tumours are not as rare as the literature would suggest. ( info) |
469/573. Sacral osseous destruction in a female gymnast: unusual manifestation of Scheuermann's disease? We describe a 14-year-old female gymnast whose complaint was that of chronic low back pain. Radiographs and computed tomograms showed both lumbar manifestations of Scheuermann's disease and an osseous destruction of the S1 vertebral body. We suggest that this is a sacral component of Scheuermann's disease. ( info) |
470/573. Intradural metastasis to the cauda equina from carcinoma of the anus. STUDY DESIGN. This is a report of a man with carcinoma of the anus and intradural metastasis to the cauda equina. OBJECTIVE. To perform a laminectomy with tumor removal for relief of pain. SUMMARY OF BACKGROUND DATA. Only 25 cases of intradural spinal metastasis have been reported in the English literature. This is the first report of a metastatic case, moving from the carcinoma of the anus to the cauda equina. methods. magnetic resonance imaging showed an ill-defined mass, with central necrosis, to the cauda equina. The possibility of intradural metastasis to the cauda equina was indicated by unique pain symptoms. RESULTS. The patient's back pain subsided after total laminectomy of L3-L5 with subtotal removal of the tumor. The residual tumor became smaller with postoperative radiation. CONCLUSION. magnetic resonance imaging is a good diagnostic choice in this situation. The cause of the metastasis was unclear, but it was presumed to have occurred through the perineural lymphatic ducts. laminectomy with tumor removal is feasible for relieving pain and demonstrating pathology. ( info) |